A 50-ish year old man presents with central crushing chest pain on a background of intermittent chest pains for a couple of days, tenuously related to exertion, maybe a bit postural, perhaps a recent coryzal illness, definitely a bit vague. This was his ECG with pain on arrival to ED:

ECG with pain

He got aspirin 300mg, a couple of sublingual GTN sprays and 5 mg of morphine rendering him pain free. Past history significant for a throat SCC treated by excision and DXRT some years previously. Continues to smoke heavily. His first troponin was <0.01.

So, is this BER, pericarditis or STEMI?

Closeup of precordial leads (ECG about 5 minutes after full one above)

Applying the Steve Smith formula for just this purpose to this ECG we get ~24.345, which is >23.4 and therefore suggests STEMI. So, is it??? Well, I left the hospital after snapping this ECG and seeing that first troponin was negative, so I don’t know the answer yet…but I will follow him up and keep y’all posted! Please comment on this post – I am keen to see what others think! Watch this space…

Steve Smith Equation value for Mr X


About dreapadoir

Emergency Physician, author of Emergency Medicine blog, photographer at
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4 Responses to STEMI vs. BER?

  1. dreapadoir says:

    Still no troponin bump – remains an inpatient today – will he or won’t he get a cath?

  2. dreapadoir says:

    Well, he never did get a cath, and he is out in the big wide world…we may never know the answer!

  3. You put the wrong number in for RA V4. It is 17 mm!! If you use that, the value of the equation comes out to 20.922 (assuming the computerized QTc was indeed 408). It looks like early repol to me, especially with the U-waves. And the equation strongly supports early repol.

    Steve Smith

    • dreapadoir says:

      You are indeed correct Steve! Thanks so much for your comment – I just went back over the real ECG, and I believe I entered the T-wave amplitude accidentally instead of the R-wave amplitude! My bad – and thanks for correcting me. I have been a using your equation a lot in practice – not sure how this one slipped through…

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