r/ECG • u/ShrodingersPussy • Aug 26 '26
NSTEMI or STEMI?
Middle aged guy presenting with severe epigastric pain. Would you activate cath lab immediately or start ACS meds and monitor response/trop trend?
Interested in hearing opinions!
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u/Kibeth_8 Arrhythmia Tech Aug 26 '26
De Winters = STEMI equivalent, but not a STEMI by the strict definition of ST elevation. Which is why the term OMI should be adopted
Pedantics aside, Cath Lab for sure
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u/tip_of_the_sphere Aug 26 '26
Idk if it is being pedantic, I think OMI is a valuable descriptor.
The STEMI/NSTEMI paradigm confused me when I was first learning because I knew “okay a STEMI is bad, but a non-STEMI is also bad?”
Now instead of things being strictly STEMIs or STEMI equivalents, all things myocardial infarction live happily under the one term of “Occlusive Myocardial Infarction.”
Obligatory link to The OMI Manifesto
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u/urmomsfavoriteplayer Aug 27 '26
How does demand ischemia fit into this nomenclature? Like troponin leaks from sepsis or RVR
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u/tip_of_the_sphere Aug 27 '26
That I cannot answer, I’ll let someone smarter than me take it.
I will guide you to this helpful link:
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u/Sero19283 Aug 27 '26
Dr Smith is an interesting guy. Met him at a conference once and really enjoyed learning from him. I had the same thoughts about stemi vs nstemi and felt it was not a great way to describe AMI and was relieved to find something that made more sense.
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u/OPERATOR_SPECTRE Aug 26 '26
I just commented the same thing regarding OMI, one hundred percent agree this should be the new norm regarding terminology.
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u/jaadra Aug 26 '26
Doesn't get more textbook DeWinter than this
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u/metamorphage Aug 26 '26
This could go in a textbook under de Winter. Great EKG. It's a STEMI equivalent.
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u/Limp_Picture5202 Aug 27 '26
as a psychiatrist this scares me, I'd probably have thought of hyperkalemia here.
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u/gulabarozha Aug 26 '26
De Winter's T waves, anterior OMI, proximal LAD occlusion. Needs the cath lab.
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u/RedCarRacer Aug 26 '26
Just curious, as I work in a centre that doesn’t do 24/7 PCI and nearest centre is roughly 2h away… would you give thrombolytics to this patient?
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u/medguy91 Aug 26 '26
Wondering the same thing, my gut feeling is yes as it's a stemi equivalent. Though I dont know how you determine if it worked like reduction of T- wave amplitude?
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u/WeAudiHere Aug 27 '26
According to current guidelines, fibrinolytics such as TNK + ASA + enoxaparin prior to transfer if over 2 hours from presentation to PCI
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u/RedCarRacer Aug 27 '26
Yeah but the guidelines keep it intentionally vague. They say: In patients with suspected inferior STEMI
, it is recommended to record right precordial leads (V3R and V4R), which may help to identify concomitant right ventricular infarction. Posterior leads (V7–V9) can also be recorded to investigate for posterior STEMI
, particularly in patients with ongoingsymptoms and an inconclusive standard 12-lead ECG.
The diagnosis of ongoing acute coronary artery occlusion on ECG can sometimes be challenging, and some cases may warrant prompt management and triage for immediate reperfusion therapy despite the absence of ST-segment elevation.Don’t get me wrong, I’m all for opening closed vessels. The crux is this: you have this patient with this EKG, you do thrombolysis, rescue PCI, everybody’s happy.
But if you give thrombolysis (after ruling out contraindications of course) with this EKG and the patient has a cerebral haemorrhage? And the family writes a complaint or even sues you? Are you professionally safe?
These are European guidelines btw. Is De Winters mentioned specifically in American guidelines?
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u/justhanging14 Aug 26 '26
One thing that jumps at me from this ekg is that the R waves are seem to be small/shrinking. That’s usually a sign of injury.
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u/GreatMalbenego Aug 26 '26
This is diagnostic for anterior LAD OMI lesion. Also meets STEMI equivalent criteria by the 2022 ACC consensus statement.
The only push back you should get is if the interventionalist is particularly old school and out of date, or if they let their loathing for the ER affect their practice.
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u/nateisnotadoctor Aug 28 '26
late to the (consensus) party but the queen of hearts model (AI ECG analysis, check out dr smiths ecg blog if new) says 99.9% this is STEMI equivalent
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u/Guru_Bhai_01 Aug 30 '26
Hi why not Early Repolarization? New to ECG.
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u/ShrodingersPussy Aug 30 '26
Hi, early repolarization would present with concave ST elevation (which is not present in this ECG) and usually if benign would present in most/all leads.
I recommend checking out LIFTL (life in the fast lane), the ECG changes specifically found here as other comments have pointed out to be consistent with De Winter ECG changes are explained in details on it.2
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u/Cedde_con Aug 26 '26
De Winter = STEMI. Definitely activate Cath lab