Do you think this EKG is a STEMI

[Porfirio]

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2:00 am STEMI - just laziness on the cardiologist standpoint. But no one tracks their miss rate, just death on table rate. Besides, it is only a miss if the cardiologist says it’s a STEMI on Monday morning.

 

[southerndoc]

Typical interventional cardiology behavior.

It's a STEMI to me in the right setting.

Yes, STEMI from 8-4. After hours or weekends, not a STEMI. Heparinize them and "cool them off."

Looks like a posterior/inferior STEMI to me.

 

[RustedFox]

Yes, STEMI from 8-4. After hours or weekends, not a STEMI. Heparinize them and "cool them off."

Looks like a posterior/inferior STEMI to me.

Like, I get it.
They're overworked. They don't wanna have to come and do the interventional thing.
But they wanna take that call money.
Can't have it both ways.
It also underscores two things: (1) America's population is getting sicker and sicker and sicker, and (2) we can't keep up and have a reasonable workload.

- and no, letting pretenders do caths and other procedures isn't a viable solution.

 

[southerndoc]

Like, I get it.
They're overworked. They don't wanna have to come and do the interventional thing.
But they wanna take that call money.
Can't have it both ways.
It also underscores two things: (1) America's population is getting sicker and sicker and sicker, and (2) we can't keep up and have a reasonable workload.

- and no, letting pretenders do caths and other procedures isn't a viable solution.

Contrary to popular belief, most specialists don't get paid to cover call. At my health system, if a hospital has 4 or more physicians covering a specialty (i.e., cardiology), then they are required to rotate a call schedule to cover all days of the month. They do this without any reimbursement.

 

[RustedFox]

Contrary to popular belief, most specialists don't get paid to cover call. At my health system, if a hospital has 4 or more physicians covering a specialty (i.e., cardiology), then they are required to rotate a call schedule to cover all days of the month. They do this without any reimbursement.

Wild to hear this (I'm not being adversarial).
Every shop I've worked in has had the "paid-to-be-on-call" arrangement.

 

[HemeOncHopeful19]

Wild to hear this (I'm not being adversarial).
Every shop I've worked in has had the "paid-to-be-on-call" arrangement.

Often it is just baked in as a requirement to maintain privileges - I don't think my group gets any $ for taking call but we do get to keep seeing our patients which keeps them from getting poached by the hospital employed guys I guess

 

[gro2001]

Bump

68 yo man with CAD p/w two hours of chest pain and nausea. BP 97/54. No respiratory distress. No prior EKG.

Initial EKG. Do you think this is a STEMI?

View attachment 393274

Spoiler: 1:

Was told EMS EKG was more convincing of a STEMI. EMS EKG was reviewed by ER doc and STEMI doc over the phone and was told no STEMI.

EKG #2 was obtained 5 minutes later. Do you think this is a STEMI? No other change in vitals or exam.

View attachment 393275

Spoiler: 2:

There was a question as to whether this is an LBBB. Do you think this is an LBBB? Again the case was discussed with the on call cardiologist, felt it was not a STEMI and asked for another EKG and troponin.

Spoiler: 3:

Third EKG is basically the same as the second. Initial Hs-Trop was 0.15. Cardiologist still felt this was not a STEMI despite the pt continuing to have real chest pain. Treat medically.

11 hours later...

Spoiler: 4:

Pt had a cath, multi-vessel disease. RCA was culprit. RCA balloon angioplastied (not stented) and it was felt pt needed a CABG. Pt transferred and had one several days later.

Spoiler: 5:

Not a clear cut LBBB, although QRS > 120. So perhaps an intraventricular conduction delay. You don't really have a broad qs wave in V1 (although maybe?). You certainly don't have a broad, clumsy R wave in V5-V6. In fact in those leads you have a pretty deep s wave, which isn't seen in an LBBB. There was discussion that this didn't meet Sgarbossa criteria. In any event the ER doc spoke to the STEMI doc multiple times about this patient and he didn't go to cath until 11 hours later. Pt did come to the ED at 0200.

This to me looks like a STEMI. In both, and especially the second. There is pretty high j-point elevation before the STE in II, more in III, and in aVF. STD by at least 2-3 mm in 1 and aVL.

To me seems like a clear cut STEMI. What did the trops peak at prior to angioplasty? If the peak trop wasn't sky high prior to revascularization I guess maybe the cardiologist was right.

 

[Radetzky]

Cardiologists and gastroenterologists hate doing their jobs I’ve learnt

 

[thegenius]

To me seems like a clear cut STEMI. What did the trops peak at prior to angioplasty? If the peak trop wasn't sky high prior to revascularization I guess maybe the cardiologist was right.

Lol. Check this out. High sensitivity trops:

15
555
13,500
80,200
195,000 (peak)

 

[Apollyon]

Lol. Check this out. High sensitivity trops:

15
555
13,500
80,200
195,000 (peak)

That's not a trop. That's an HCG!

 

[TooMuchResearch]

I already read the thread but yes, that's a STEMI.

 

[gro2001]

Lol. Check this out. High sensitivity trops:

15
555
13,500
80,200
195,000 (peak)

Umm yeah, that seems high enough.

 

[maxxor]

Contrary to popular belief, most specialists don't get paid to cover call. At my health system, if a hospital has 4 or more physicians covering a specialty (i.e., cardiology), then they are required to rotate a call schedule to cover all days of the month. They do this without any reimbursement.

The longer I work in our state, the more I realize it doesn’t function like other states…

 

[emergentmd]

Given age, altered and that EKG? I would bedside text the EKG to Cards and let them decide. I would not have called a STEMI unless cards agreed.

I just had a 29 YO 6'0" 170lb guy with zero risk factors and zero family hx of early CAD/MI. Came in with Chest pain after finishing a football game but he plays football all the time. Came in with chest pressure and appeared anxious without hx of anxiety.

EKG looked like a lateral wall MI. Still didn't calla Stemi immediately. Text the EKG to my cards friend and said suspicious so agreed with activation which took me 3-5 minutes to get the bedside consult. Activated, and STEMI doc called me back saying prob pericarditis and asked for EKG. Text him the EKG and he said, yeah looks concerning. Went to Cath and had a complete LAD.

I have been doing EM for 25 yrs and one of my golden rules is anyone in their 20's without family hx of early CAD never is a blocked artery. This broke my golden rule.

 

[emergentmd]

Bump

68 yo man with CAD p/w two hours of chest pain and nausea. BP 97/54. No respiratory distress. No prior EKG.

Initial EKG. Do you think this is a STEMI?

View attachment 393274

Spoiler: 1:

Was told EMS EKG was more convincing of a STEMI. EMS EKG was reviewed by ER doc and STEMI doc over the phone and was told no STEMI.

EKG #2 was obtained 5 minutes later. Do you think this is a STEMI? No other change in vitals or exam.

View attachment 393275

Spoiler: 2:

There was a question as to whether this is an LBBB. Do you think this is an LBBB? Again the case was discussed with the on call cardiologist, felt it was not a STEMI and asked for another EKG and troponin.

Spoiler: 3:

Third EKG is basically the same as the second. Initial Hs-Trop was 0.15. Cardiologist still felt this was not a STEMI despite the pt continuing to have real chest pain. Treat medically.

11 hours later...

Spoiler: 4:

Pt had a cath, multi-vessel disease. RCA was culprit. RCA balloon angioplastied (not stented) and it was felt pt needed a CABG. Pt transferred and had one several days later.

Spoiler: 5:

Not a clear cut LBBB, although QRS > 120. So perhaps an intraventricular conduction delay. You don't really have a broad qs wave in V1 (although maybe?). You certainly don't have a broad, clumsy R wave in V5-V6. In fact in those leads you have a pretty deep s wave, which isn't seen in an LBBB. There was discussion that this didn't meet Sgarbossa criteria. In any event the ER doc spoke to the STEMI doc multiple times about this patient and he didn't go to cath until 11 hours later. Pt did come to the ED at 0200.

This to me looks like a STEMI. In both, and especially the second. There is pretty high j-point elevation before the STE in II, more in III, and in aVF. STD by at least 2-3 mm in 1 and aVL.

No Brainer, activate. Inferior ST elevation and good story.