# Standardized STEMI Identification Assessment



## Christopher (Jun 11, 2014)

I've worked on putting online a standardized STEMI Identification Assessment using 36 ECG's from a survey-based study on STEMI identification by physicians. It originally utilized a Google Form and would email you a huge 9MB PDF with your results. I've now converted it over to a Google site as a proof of concept.

I would be much obliged if folks could take this assessment and see what bugs, if any, are present. I know it works in IE9, IE10, Firefox, and Chrome; but that's all I've tested it in.

After you take the test it will tell you your accuracy, sensitivity, specificity, and how you compared versus computerized interpretation, emergency physicians, and cardiologists. It'll also tell you what sort of ECG's you miss ("subtle", "LVH", etc) and whether they cause you to make false positives or false negatives. It also lets you know whether your answer for each ECG was consistent with the physician's answers.

Your email address is optional, but it can be helpful if you encounter a problem for me to look up your results.

Thank you for your time!

Take the test here, see if you find any bugs, and see how you stack up against man and machine!


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## TomB (Jun 11, 2014)

Good Lord, Christopher! There's not a straight forward ECG in that entire test. Each was was difficult, IMHO. I would not feel comfortable calling any of them a STEMI without clinical correlation. My accuracy: 83% with 2 false positives and 4 false negatives (I answered conservatively). You could see many of these STEMI-like ECGs with other diagnoses (e.g., sepsis, etc.). I think paramedics and physicians alike would have extreme difficulty with this test.

Tom


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## Christopher (Jun 11, 2014)

TomB said:


> Good Lord, Christopher! There's not a straight forward ECG in that entire test. Each was was difficult, IMHO. I would not feel comfortable calling any of them a STEMI without clinical correlation. My accuracy: 83% with 2 false positives and 4 false negatives (I answered conservatively). You could see many of these STEMI-like ECGs with other diagnoses (e.g., sepsis, etc.). I think paramedics and physicians alike would have extreme difficulty with this test.
> 
> Tom



I enjoyed the test when I learned all 36 ECG's were actual STEMI activations (which I take to mean somebody thought adequate clinical correlation existed).


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## Handsome Robb (Jun 11, 2014)

I did better than I thought after seeing those ECGs....shoulda known when Tom said something that I was in for an adventure. 

78% accuracy, sensitivity 71% and specificity of 92%
1 false positive and .... 7 false negatives. 

I agree about it being difficult without any sort of clinical correlation. 

Thanks for this Christopher!


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## Ewok Jerky (Jun 11, 2014)

Very cool, thank you Christopher. In retrospect I wish I hadn't done it on my phone and pulled out my calipers...did better than the algorithm but not quite as good as a physician.

I think this is really difficult without clinical context, but a good exercise regardless.


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## teedubbyaw (Jun 11, 2014)

"This ECG shows an anteroseptal myocardial infarction *with reciprocal changes in the inferior leads*."

That's not something I remember learning.

or this
"Marked elevation is visible in V3 and V4, with subtle ST-depression in lead III, cinching the diagnosis of STEMI."


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## MonkeyArrow (Jun 11, 2014)

For the record, if you see someone who absolutely bombed it and looked like they almost guessed their way through, it's cause they did . You said to check for bugs, and no, I didn't find anything. So, yeah, you may wanna exclude that one outlier who got the easy ones wrong and the hard ones right. The wonderful powers of guessing on a phone combined with 50/50 odds.


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## medicsb (Jun 11, 2014)

No bugs.  Good test; not easy at all!

My results:
Your accuracy was: 83 %
Your sensitivity was: 88 %
Your specificity was: 75 %
You had 3 false positive(s) and 3 false negative(s).


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## TransportJockey (Jun 11, 2014)

I'll have to take it on my computer. For some reason chrome on my phone didn't like the site


EDIT: Dear god I thought I was good at interpreting ECGs... But maybe not as much as I thought
Your accuracy was: 75 %
Your sensitivity was: 79 %
Your specificity was: 67 %
You had 4 false positive(s) and 5 false negative(s).


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## Christopher (Jun 12, 2014)

MonkeyArrow said:


> For the record, if you see someone who absolutely bombed it and looked like they almost guessed their way through, it's cause they did . You said to check for bugs, and no, I didn't find anything. So, yeah, you may wanna exclude that one outlier who got the easy ones wrong and the hard ones right. The wonderful powers of guessing on a phone combined with 50/50 odds.



Do you remember roughly when you took it or what your accuracy was so I can exclude it?


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## Christopher (Jun 12, 2014)

teedubbyaw said:


> "This ECG shows an anteroseptal myocardial infarction *with reciprocal changes in the inferior leads*."
> 
> That's not something I remember learning.
> 
> ...



Part of the problem with current STEMI education is the misunderstanding as to what ST-depression actually means. Most textbooks will tell you localized depression is either (A) reciprocal change, or (B) focal ischemia.

The truth is only A is correct.

Ischemia instead produces diffuse ST-depression found in multiple leads. Localized ST-depression is a reciprocal change.

Many of these ECG's have a correct answer found by a careful analysis of ST-depression.


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## Christopher (Jun 12, 2014)

Handsome Robb said:


> 78% accuracy, sensitivity 71% and specificity of 92%
> 1 false positive and .... 7 false negatives.





medicsb said:


> Your accuracy was: 83 %
> Your sensitivity was: 88 %
> Your specificity was: 75 %
> You had 3 false positive(s) and 3 false negative(s).





TransportJockey said:


> Your accuracy was: 75 %
> Your sensitivity was: 79 %
> Your specificity was: 67 %
> You had 4 false positive(s) and 5 false negative(s).



These are good "scores"; consider that the cardiologists didn't do much better at all.

Most false negatives I see are based on our current "understanding" of a STEMI being based on arbitrary millimeter criteria. If your false negatives included the phrase "subtle", that is par for the course.

5 or less false positives is consistent with a healthy STEMI system. The only way to be certain that your false positives are "Ok" is to analyze the ECG for *why* it isn't a STEMI and to see if your reasoning was sound. Artifact? Uncomplicated LVH? Uncomplicated LBBB? Those I'd say we shouldn't be mistaking for a STEMI. Other situations may not be so clear and are probably quite appropriate.


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## teedubbyaw (Jun 12, 2014)

Christopher said:


> Part of the problem with current STEMI education is the misunderstanding as to what ST-depression actually means. Most textbooks will tell you localized depression is either (A) reciprocal change, or (B) focal ischemia.
> 
> The truth is only A is correct.
> 
> ...



Another issue is that the extent of reciprocal changes I learned was inferior/lateral/posterior. I've always thought I was pretty good with 12 leads, but that's an eye opener that there's still a lot more to learn.


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## Christopher (Jun 12, 2014)

teedubbyaw said:


> Another issue is that the extent of reciprocal changes I learned was inferior/lateral/posterior. I've always thought I was pretty good with 12 leads, but that's an eye opener that there's still a lot more to learn.



I like to think of the changes in terms of a three dimensional continuous model of the heart...or in less engineery terms...a sphere of electrical tissue floating in space. Using exact definitions are unlikely to be anything but approximations of an approximation (aka. wild *** guess).

My favorite picture to use is this one from the Life in the Fast Lane crew. If you imagine yourself in space, floating with the heart, you can picture how something like an anteroseptal MI (perhaps due to a proximal or mid LAD lesion) could affect the inferior leads.

It also helps to realize that the frontal leads and the precordial leads are _different_ in how they record electricity...but are in some ways equivalent. So yes, while the inferior leads technically follow a plane that cuts the body in two halves front-to-back, it isn't quite that simple.

Anyways...I came out of class knowing a lot about ECG's.

Then I hung out with some really smart folks and realized I came out of class knowing the bare minimum about ECG's....


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## MonkeyArrow (Jun 12, 2014)

Christopher said:


> Do you remember roughly when you took it or what your accuracy was so I can exclude it?



Yeah. I took it yesterday around 8ish pm. I believe accuracy was somewhere around 53%. Sensitivity was around 70 and specificity right at 50 if I'm not mistaken.

Sorry :unsure:


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## Christopher (Jun 12, 2014)

MonkeyArrow said:


> Yeah. I took it yesterday around 8ish pm. I believe acc. was somewhere around 53%. Sensitivity was around 70 and specificity right at 50 if I'm not mistaken.
> 
> Sorry :unsure:



No worries!


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## 9D4 (Jun 12, 2014)

Well... I set myself up for failure on that one. Seeing all these guys in the 70's... 
Considering I've only had 1 12 lead class, I guess i'll live with it... 

Your accuracy was: 56 %
Your sensitivity was: 67 %
Your specificity was: 33 %
You had 8 false positive(s) and 8 false negative(s).

:unsure:


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## Christopher (Jun 12, 2014)

9D4 said:


> Well... I set myself up for failure on that one. Seeing all these guys in the 70's...
> Considering I've only had 1 12 lead class, I guess i'll live with it...
> 
> Your accuracy was: 56 %
> ...



Honestly you did fine. Look through the ECG's you "missed" and see how subtle they were or whether it was due to one of the more common causes of ST-elevation (of which AMI is an uncommon cause...although in this cohort it was).


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## 9D4 (Jun 12, 2014)

Christopher said:


> Honestly you did fine. Look through the ECG's you "missed" and see how subtle they were or whether it was due to one of the more common causes of ST-elevation (of which AMI is an uncommon cause...although in this cohort it was).



One of them was a mis click if that matters 

For the most part, the ones I missed, I think I rushed through. Half of them were very obvious looking back. The other half... Very,very subtle, so.... I guess there's no middle ground? Haha


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## Jon (Jun 12, 2014)

TomB said:


> Good Lord, Christopher! There's not a straight forward ECG in that entire test. Each was was difficult, IMHO. I would not feel comfortable calling any of them a STEMI without clinical correlation. My accuracy: 83% with 2 false positives and 4 false negatives (I answered conservatively). You could see many of these STEMI-like ECGs with other diagnoses (e.g., sepsis, etc.). I think paramedics and physicians alike would have extreme difficulty with this test.
> 
> Tom



If Tom only got an 83%, I feel slightly better with my score


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## Christopher (Jun 13, 2014)

9D4 said:


> One of them was a mis click if that matters
> 
> For the most part, the ones I missed, I think I rushed through. Half of them were very obvious looking back. The other half... Very,very subtle, so.... I guess there's no middle ground? Haha



I always tell my students when I grade a multiple choice exam that I can't differentiate between a mistaken answer and an incorrect answer, hence we only cover questions that more than 25% of the class missed.

"Subtle" is only because our guidelines for STEMI are not based in reality. Your heart has no idea what a millimeter is (for all we know it still uses English units), so why on earth do we think 1mm+ in 2+ contiguous leads is going to be the end-all-be-all of STEMI identification?

Besides, those criteria were developed in the age of thrombolytics and by "developed" I mean chosen rather arbitrarily as there have not been any trials to determine the optimal cutoffs. You can tell they're not grounded in reality when they have these exceptions like ">1.5mm in V2 and >2mm in V3 for yada yada yada", because they do not account for proportionality or normal variants.



Jon said:


> If Tom only got an 83%, I feel slightly better with my score



You can score a respectable 70% and have a horrible number of false positives. Accuracy is not nearly as important as a reasonable sensitivity/specificity, and nowhere near as important as an item-by-item review of what you missed and _why_.


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## Christopher (Jun 16, 2014)

Thank you to everyone (n=35) who has taken this so far!

This group was mostly paramedics, but included RN's, PA/NP's, technicians, and med students. The comfort level was right in the middle (4 out of 7), and most read roughly 3-5 ECG's per week. Combined accuracy of 68%, false positive rate of 12%, and a false negative rate of 21%.

The previous cohort of paramedics (n=16) who took this for me was local and skewed towards a higher comfort level (6 out of 7, "near expert"), and skewed towards more ECG's read per month. They had an accuracy of 77%, false positive rate of 5%, and a false negative rate of 18%.

In both cohorts I've run there is an increase in accuracy, and a decrease in FP and FN rates as you increase the number of ECG's you read in a month. Read more ECG's!

The original McCabe study looked at physicians of multiple levels (n=85), most of whom had a lot of ECG experience. Their combined accuracy was 70%, with a 7% false positive rate, and a 23% false negative rate.

What I've noticed is while the accuracies are roughly similar (excluding my local cohort), which ECG's the groups disagreed upon were quite different.

Paramedics think these ECG's are _easy_, and overwhelmingly get it right while the MD's miss them: subtle IWMI with recip change in aVL, hyperacute AWMI with recip change in aVL, anteroseptal MI with recip changes inferiorly.

Likewise, this cohort and even the more accurate local group of medics had problems with these ECGs when compared to the MD's: IWMI w/ tachycardia, Wellen's syndrome (although I'm sure this is rarely associated with "acute" for EMS).

These ECG's it seemed our group had the same problems the MD's had (respondents combined <50% correct): subtle lateral wall MI, posterior MI w/ AVB, subtle lateral wall MI, subtle inferior wall MI.

Key takeaways:

Read more ECG's 
Ischemic ST-depression does not localize! Localized ST-depression is a reciprocal change until proven otherwise.
Your heart has no idea what a millimeter is, do it a favor and forget absolute criteria; allll things in proportion!
Level of education does not seem to matter as much as ECG experience; medic vs MD who cares!


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## teedubbyaw (Jun 16, 2014)

Thank you, Christopher. Don't stop sharing your knowledge on these forums!


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## socalmedic (Jun 18, 2014)

I tried doing this at work and found a bug/glitch. I kept getting this after the basic demographics page.

"Script function not found: doPost"

Windows 7, IE 9 version 9.0.8112.16421 update 9.0.23. DSL 3Mbt down.


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## Christopher (Jun 18, 2014)

socalmedic said:


> I tried doing this at work and found a bug/glitch. I kept getting this after the basic demographics page.
> 
> "Script function not found: doPost"
> 
> Windows 7, IE 9 version 9.0.8112.16421 update 9.0.23. DSL 3Mbt down.



Interesting. It runs under Google's Caja sandbox, which supposedly works on IE9+ but perhaps not.

I'll look into it!


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## chaz90 (Jun 18, 2014)

Well. I did a remarkably poor job on that bad boy. Good information though!


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## Smash (Jun 19, 2014)

Would not work on Chrome running on Android device.  Would go through the quiz, would not display results.

Just curious regarding Wellen's for this, are you considering this a STEMI equivalent or sub-acute/reperfused?  Our cath labs don't want us activating for Wellen's.


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## Christopher (Jun 19, 2014)

Smash said:


> Would not work on Chrome running on Android device.  Would go through the quiz, would not display results.



If you tell me roughly when you took it I can PM you your results.



Smash said:


> Just curious regarding Wellen's for this, are you considering this a STEMI equivalent or sub-acute/reperfused?  Our cath labs don't want us activating for Wellen's.



That's a great question, one that is better left to the System itself. Wellen's is no more or less a coronary artery occlusion event than your traditional STEMI, and perhaps even more insidious as it can be mistaken for angina. The point of this assessment was to see how well folks perform at the identification of coronary artery occlusion. Whether your system wants you to activate on Wellen's is another question entirely, one of sensitivity and resource usage!


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## Clare (Jun 19, 2014)

Sensitivity 67 %
Specificity 75 %
Positive Predictive Value 84 %
Negative Predictive Value 53 %

Thanks for this; it was very informative and interesting.  

I am OK with run of the mill STEMIs and other such ST abnormalities but I get lost in the more complex stuff like STEMI in the presence of LBBB.

While probably a lame endpoint, when in doubt, refer to hospital with a cath lab!


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## Brandon O (Jun 19, 2014)

Smash said:


> Just curious regarding Wellen's for this, are you considering this a STEMI equivalent or sub-acute/reperfused?  Our cath labs don't want us activating for Wellen's.



I griped about this too, just because definitionally it's not a STEMI. (Of course, if we're getting out the dictionary, neither is an isolated posterior, but I hope you take my point.) Just one of those lawyer things.


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## blindsideflank (Jun 20, 2014)

Your accuracy was: 72 %
Your sensitivity was: 58 %
Your specificity was: 100 %
You had 0 false positive(s) and 10 false negative(s).


weird, if anything I would have said i miss more positives than I falsely diagnose in the field


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## STXmedic (Jun 20, 2014)

As soon as I get out of the hospital, I'll be taking this.


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## Christopher (Jun 20, 2014)

Brandon O said:


> I griped about this too, just because definitionally it's not a STEMI. (Of course, if we're getting out the dictionary, neither is an isolated posterior, but I hope you take my point.) Just one of those lawyer things.



I swear we need a better phrase for this...I still get crap for "well that's not 1 millimeter". Perhaps Code OOYHLMFHBCOMCA: one of y'all hospital lookin' monkey flippers had better check out my coronary arteries?

It's unfortunate that the term we use is based on an insensitive criteria.


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## Christopher (Jun 20, 2014)

blindsideflank said:


> Your accuracy was: 72 %
> Your sensitivity was: 58 %
> Your specificity was: 100 %
> You had 0 false positive(s) and 10 false negative(s).
> ...



This dataset has a number of subtle coronary artery occlusions, those which serial ECG's _may_ pick up. Perhaps they represent conditions where you wouldn't activate off the initial ECG.


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## Smash (Jun 21, 2014)

If you don't mind Christopher, I would like to put a link up to this on my blog.


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## Christopher (Jun 21, 2014)

Smash said:


> If you don't mind Christopher, I would like to put a link up to this on my blog.



Feel free bud, thanks!


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## Chimpie (Jun 21, 2014)

Just put a link to this thread up on our Facebook page. Hopefully you'll get a few more participants.


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## socalmedic (Jun 21, 2014)

Chimpie said:


> Just put a link to this thread up on our Facebook page. Hopefully you'll get a few more participants.



we have a Facebook page?


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## Chimpie (Jun 21, 2014)

socalmedic said:


> we have a Facebook page?



Yep, and Twitter. Links below, but let's try to stay on topic. Thanks!


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## TomB (Jun 23, 2014)

I took the test again with the idea that: 1.) there was clinical correlation with typical signs/symptoms of ACS. 2.) that the standard was "do I think it's an occluded artery" with the understanding that the ECGs were taken from an academic paper on the topic. 

That's a different standard from "would I call a Code STEMI from the field" since many of them don't meet our Code STEMI criteria (which I designed).

So in the "risk free" testing environment I got one false positive and one false negative. The false positive was probably Wellens (I wasn't sure how the test would score Wellens) and the false negative was reportedly acute anterior STEMI which looked to me like ventricular aneurysm or LVH with strain.

Anyway, if you haven't taken the test in a while I would take it again! Christopher has made some improvements. It will rate you against other health care disciplines, show you which ones you got wrong, etc. (If it did that before I missed it).

Robert Simpson from AmboFOAM blogged about it, too (is that one of you?)

http://ambofoam.wordpress.com/2014/06/22/so-you-think-you-can-spot-a-stemi/ 

Tom


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## gronch (Jun 23, 2014)

This test motivated me.  Thank you.

Is it okay to pass this on to my nurse wife and her nurse friends?


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## Christopher (Jun 23, 2014)

gronch said:


> This test motivated me.  Thank you.
> 
> Is it okay to pass this on to my nurse wife and her nurse friends?



More than Ok!


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## TransportJockey (Jun 23, 2014)

I'm leaving this test up on some of our company computers to see if anyone else will take it


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## Christopher (Jun 23, 2014)

560 folks have taken the assessment (now 561...it goes up up up), and really not much has changed!

Acc: 67%
False Positive rate: 11%
False Negative rate: 22%
Sensitivity: 67%
Specificity: 66%

That's almost identical to when it was just 40 people!

Some interesting subgroup analysis though:

Self identified NP/PA's as a group scored the highest overall (n=11). 72% accuracy, 10% FP rate, 19% FN rate.
Attendings/GPs were not far behind (n=13). 71% accuracy, 12% FP rate, 16% FN rate.
Residents and Paramedics are nearly indistinguishable, with the residents holding a slight edge in false negative rates (21% vs 22%).
The "best" scorer group (>90%) have at least one: MD, resident, NP/PA, med student, RN, paramedic, EMT, and technician (nobody non-medical). No one specialty dominates among the top performers.
When we ignore the license/cert/card/title, reading at least 1 ECG a day keeps the false positives and negatives away.


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## Frozennoodle (Jun 23, 2014)

Your accuracy was: 83 %
Your sensitivity was: 92 %
Your specificity was: 67 %
You had 4 false positive(s) and 2 false negative(s).


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## rmena (Jun 24, 2014)

So wait..explain the st-depression again. This was a big source for debate in my medic class. So how I was taught is that if there is depression in II, III or avf there will be elevation in one of the other set of leads and vice versa (that was how they explained reciprocal determinism). Explain the diffuse ischemia version of depression then to me. It was also taught that all you need is 1mm box to activate the cath. lab and that it had to be in two consecutive leads. (ie if you had elevation in V1 it had to be in V2 as well).


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## Brandon O (Jun 24, 2014)

Other than reciprocal changes, it's traditionally taught that ST depression can also signify subendocardial ischemia (in other words, not a complete STEMI, just ischemia). This is true, but there's a misconception that this can be localized on the ECG in the same way as ST elevation. True subendocardial ischemia is usually widespread, or at least not localized anatomically. An anatomical pattern of depression (e.g. inferior leads or anterior leads) is more likely to indicate reciprocal changes.


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## rmena (Jun 24, 2014)

So ischemia will show up in like....V1-V4 as opposed to just V1 and 2? If it just shows up in V1 and V2 I am looking for elevation in II, III, and aVF?


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## Brandon O (Jun 24, 2014)

rmena said:


> So ischemia will show up in like....V1-V4 as opposed to just V1 and 2? If it just shows up in V1 and V2 I am looking for elevation in II, III, and aVF?



All of the precordials are somewhat contiguous, although it's unusual for a pattern to stretch all the way across. But yes, compare for reciprocals in the inferiors and vice versa (or hidden elevation in the posterior wall).

As for mere ischemia, it's not uncommon to see it in practically every lead. This is a common finding in stress tests as well as tachyarrhythmias (demand ischemia -- heart's working harder than the blood supply can oxygenate). Even if it's not global, you won't see reciprocal elevation anywhere.


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## rugbyguy (Jul 3, 2014)

TomB said:


> Good Lord, Christopher! There's not a straight forward ECG in that entire test. Each was was difficult, IMHO. I would not feel comfortable calling any of them a STEMI without clinical correlation. My accuracy: 83% with 2 false positives and 4 false negatives (I answered conservatively). You could see many of these STEMI-like ECGs with other diagnoses (e.g., sepsis, etc.). I think paramedics and physicians alike would have extreme difficulty with this test.
> 
> Tom



All cardiologists say they would rather get a false positive, than one that isnt called in. We saw one we thought was a stemi, called it  in, got to the hospital, it was pericarditis. Doc said he would want us to call that in as a stemi 10/10. That being said, it's pretty embarrassing when you call in something obviously not a stemi.


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## TomB (Jul 5, 2014)

All cardiologists say that until they are called in at 0300 for a paced rhythm or because artifact triggered the ***ACUTE MI SUSPECTED*** message on the prehospital 12-lead ECG. Pericarditis is a special case because it's rare and widespread ST-elevation could also be a massive STEMI. Every system has a false positive rate but very few hospitals will speak about it publicly. In many hospitals it's in the 30% range (I'm not talking about paramedic-activated STEMI cases in particular). Having false positives, by itself, is nothing to be ashamed of. OTOH, there are false positives (and false negatives) that simply should not happen, but do.


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## Christopher (Jul 8, 2014)

Due to its insane popularity, I've begun work on vNext of the assessment (sneak peek pics are here). The images have already been moved to a content delivery service, and I'm moving off Google Apps to an actual website with an actual database*.

If you included your email in the first go-around, I'm going to work on migrating your results to the new version. I haven't figured out exactly how to handle the account sign-up bit...but likely you'll get an invitation email with a magic link and stuff. Tentatively the site will allow Guests...but who knows!

The closed beta will include just the McCabe assessment, so you won't get a chance to bust your chops on any new ECG's.

Again, thank you for all of the support!

* for those interested: Amazon Web Services is hosting the server, an EC2 instance running Debian Wheezy. Site served via nginx, proxying dynamic requests to node.js+express.js 4, dynamic client side scripting with Jade templates and Knockout.js, CSS is via Twitter's Bootstrap. Data layer housed in a combination of REDIS and MySQL (Amazon ElastiCache and RDS respectively). Static content served via Amazon's CloudFront + S3.</nerdalert>


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## Tunamate (Jul 14, 2014)

That is awesome dude
seriously cool stuff



Christopher said:


> Due to its insane popularity, I've begun work on vNext of the assessment (sneak peek pics are here). The images have already been moved to a content delivery service, and I'm moving off Google Apps to an actual website with an actual database*.
> 
> If you included your email in the first go-around, I'm going to work on migrating your results to the new version. I haven't figured out exactly how to handle the account sign-up bit...but likely you'll get an invitation email with a magic link and stuff. Tentatively the site will allow Guests...but who knows!
> 
> ...


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## Christopher (Jul 14, 2014)

Tunamate said:


> That is awesome dude
> seriously cool stuff



Thank you!

For those technically inclined here is a picture of how the sausage is being made.


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## Christopher (Jul 14, 2014)

And for those who are still following this thread, I'm trialing an ECG viewing feature and would like user input on its "look and feel"...and whether my hackjob CSS/JS actually works 

http://s3.amazonaws.com/ecgs/sp/lightbox.html

I'm begging, borrowing, and stealing the look/feel that Wikipedia has moved to for images.

Also of interest is how this looks on tablets / phones of various types/etc.

Any bugs you may find, I'd love to know about:
- I already know that image zooming on phones gets a bit odd...I'll probably provide a fullscreen mode for that.

Thank you!


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## WoodyPN (Jul 31, 2014)

Took this in class. There were definitely some challenging ones in there. Thanks


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## Christopher (Aug 1, 2014)

WoodyPN said:


> Took this in class. There were definitely some challenging ones in there. Thanks



Thank you for the support. vNext is approaching rapidly. If you used your email address you will have an account waiting for you in the new system.


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## Mantis Toboggan (Feb 1, 2015)

this is an outstanding little quiz. I remember attempting the very same assessment about a year ago, when a fellow student recommended it in our cardiology class.  I don't recall how I fared the first time—dreadfully, I'm sure.  Today I scored with 89% accuracy [96% sensitivity/75% specificity] from the 36 mentally-straining ECGs, and I'm cool with that.


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## systemet (Feb 1, 2015)

Your accuracy was: *78 %*
Your sensitivity was: 67 %
Your specificity was: 100 %
You had *0* false positive(s) and *8* false negative(s).
================================

Not very happy about the 8 false-negatives


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## systemet (Feb 1, 2015)

So I've had a chance to go back through my results, and now I'm a little happier.  The ECG I thought was Wellen's syndrome is a good beat.  I missed at least one very blatant STEMI, I'm still not sure how.  My biggest downfall was failing to consider absolutely small but proportionately large ST changes in the inferior leads, and I obviously have a need to be a little more systematic, and less reliance on strict reference values.

This is an excellent teaching / learning resource.  Thanks for producing this!


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