Occlusive Myocardial Infarction, ECGs and AI with Steve Smith

Podcast – Occlusive Myocardial Infarction, ECGs and Artificial Intelligence with Steve Smith

It was a huge pleasure to sit down with Steve Smith, a name synonymous with ECG expertise. Steve, renowned worldwide for his influential ECG blog, has been a pivotal figure in advancing our understanding of ECGs. Many of us have honed our ECG skills thanks to Steve’s insights. I had the opportunity to meet Steve about a decade ago at one of the SMACC conferences. Today, we delve into the fascinating world of occlusive myocardial infarction (OMI) and its comparison to STEMI (ST-elevation myocardial infarction), and explore the promising future of artificial intelligence in ECG interpretation.

Listening Time – 27:40

Exploring OMI: A Revolutionary Approach to ECG Interpretation with Steve Smith

A Legacy in Emergency Medicine and ECGs

Steve began his journey in emergency medicine 37 years ago, starting at Hennepin County Medical Centre in 1987, where he continues to work and teach residents and students. His interest in EKGs sparked in 1989 while working in the cardiac care unit. Faced with the critical decision of administering thrombolytics, Steve realized the importance of accurately interpreting EKGs to avoid false positives and potential intracranial bleeds. This led him to write “The ECG in Acute MI: An Evidence-Based Manual of Reperfusion Therapy” in 2002.

In 2008, Steve launched Dr. Smith’s ECG blog, one of the pioneering FOAMed sites, which remains free and highly regarded in the medical community. With over 1,700 posts, the blog covers a vast array of rhythm cases, but primarily focuses on OMI, which Steve considers the most crucial aspect of EKG interpretation.

Challenging the STEMI/NSTEMI Dichotomy

In 2014, during a talk at SMACC in Australia, Steve introduced the concept of the false STEMI/NSTEMI dichotomy. He argued that ST elevation is an inadequate marker for diagnosing acute coronary occlusion due to its lack of sensitivity and specificity. This led to the publication of the OMI Manifesto in 2018, advocating for the replacement of STEMI/NSTEMI with OMI/NOMI. Steve and his team have published numerous papers demonstrating that his approach to EKG interpretation is significantly more sensitive than traditional STEMI criteria.

The Data Behind Occlusive Myocardial Infarction (OMI)

Steve’s challenge to the STEMI paradigm is backed by substantial data. For instance, a study by Kojima in 2002 found that 55% of STEMI and 45% of NSTEMI patients had completely occluded arteries, both with similar mortality rates. A 2017 meta-analysis revealed that 25% of NSTEMI patients had a completely occluded artery on next-day angiogram, with these patients experiencing double the mortality compared to those with open arteries. Further studies have consistently shown higher mortality rates for patients with NSTEMI OMI compared to NSTEMI NOMI.

Identifying OMI: Beyond ST Elevation

For those familiar with the blog, identifying OMI involves looking beyond ST elevation. Subtle ST elevation, reciprocal ST depression, and other specific patterns can indicate acute coronary occlusion. Steve developed a four-variable formula, published on MDCalc, that uses the R wave amplitude in V4, QRS amplitude in V2, ST elevation in V3, and the QTc interval to diagnose LAD occlusion with high sensitivity and specificity. Although these rules are complex, they provide crucial insights into EKG interpretation.

The Role of AI in ECG Interpretation

Recognizing the potential of AI to revolutionize ECG interpretation, Steve collaborated with Powerful Medical, a company based in Bratislava, Slovakia. This partnership aimed to train AI to identify OMI as accurately as an expert. Powerful Medical’s Queen of Hearts AI, trained on thousands of EKGs, has shown remarkable accuracy in detecting OMI.

Validating AI: The Queen of Hearts

Several studies validate the efficacy of the Queen of Hearts. In one study, it demonstrated double the sensitivity of STEMI criteria. In another, it significantly reduced false positives in pre-hospital cath lab activations. At Ulst Belgium, the implementation of the Queen of Hearts reduced the median time to intervention for NSTEMI with occlusion from 16 hours to 1.4 hours.

Implementing AI in Emergency Departments

As an emergency physician in the UK, I see a significant advantage in using the Queen of Hearts for initial ECG interpretation. In a study of 51 cases of acute coronary occlusion misdiagnosed as normal by conventional algorithms, the Queen of Hearts correctly identified 38 as OMI. This demonstrates its potential to act as an initial filter, significantly reducing the burden on clinicians.

The Future of AI in ECG Machines

Integrating AI into ECG machines will require negotiation with major companies and likely FDA approval in the United States. However, once approved, the Queen of Hearts could be a game-changer in emergency departments worldwide.

Getting Started with the Queen of Hearts

For those interested in exploring this technology, the Queen of Hearts app, PM Cardio, is available on Android and Apple. The trial version allows for free use and provides a comprehensive analysis of EKGs, identifying occlusive myocardial infarction, bundle branch blocks, rhythm disturbances, and more. This tool can alleviate the stress on junior clinicians and improve patient outcomes by providing accurate and timely diagnoses.


The integration of AI in ECG interpretation, spearheaded by Steve Smith and Powerful Medical, marks a significant advancement in emergency medicine. By shifting from the outdated STEMI/NSTEMI paradigm to the more accurate OMI/NOMI approach, and leveraging the power of AI, we can improve diagnostic accuracy and patient care. Visit Dr. Smith’s ECG blog to learn more and try out the Queen of Hearts app to experience this revolutionary technology firsthand.

You can find out more about downloading the app here

Further Resources

OMI Literature Timeline: Key References (from Dr Smith’s ECG Blog)



  • Meyers & Smith: “Prospective, real-world evidence showing the gap between STEMI and OMI,” International Journal of Cardiology.


  • Aslanger, Smith, et al.: “DIagnostic accuracy oF electrocardiogram for acute coronary OCClUsion resuLTing in myocardial infarction,” International Journal of Cardiology Heart & Vasculature.
  • Meyers, Bracey, Smith, et al.: “Comparison of the STEMI vs. NSTEMI and OMI vs. NOMI paradigms of acute MI,” Journal of Emergency Medicine.


  • Tziakas, Chalikias, Al-Lamee, Kaski: “Total coronary occlusion in non-ST elevation myocardial infarction: Time to change our practice?” International Journal of Cardiology.
  • Meyers, Bracey, Smith, et al.: “Accuracy of OMI ECG findings versus STEMI criteria for diagnosis of acute coronary occlusion myocardial infarction,” International Journal of Cardiology Heart & Vasculature.
  • Aslanger, Meyers, Smith: “STEMI: A transitional fossil in MI classification?” Journal of Electrocardiography.


  • Xu, C et al.: “Point-of-care ultrasound may expedite diagnosis and revascularization of occult occlusive myocardial infarction,” AJEM.
  • Lindow T et al.: “Low diagnostic yield of STEMI amplitude criteria in chest pain patients at the emergency department,” Scandinavian Cardiovascular Journal.
  • Al-Zaiti S, Macleod R, Van Dam P, Smith SW, Birnbaum Y: “Emerging ECG Methods for Acute Coronary Syndrome Detection: Recommendations and Future Opportunities,” Journal of Electrocardiology.
  • Kontos et al.: “2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department,” JACC.


  • Sharma M et al.: “Occluded Coronary Artery among Non-ST Elevation Myocardial Infarction Patients in Department of Cardiology of a Tertiary Care Centre: A Descriptive Cross-sectional Study,” J Nepal Med Assoc.
  • Zoni CR, Mukherjee D, Gulati M: “Proposed new classification for acute coronary syndrome: acute coronary syndrome requiring immediate reperfusion,” Catheterization and Cardiovascular Interventions.
  • Meyers HP, Smith SW: “Hyperacute T-waves Can Be a Useful Sign of Occlusion Myocardial Infarction if Appropriately Defined,” Annals of Emergency Medicine.
  • McLaren J, Meyers HP, Smith SW: “Kenichi Harumi Plenary Address at Annual Meeting of the International Society of Computers in Electrocardiology: ‘What Should ECG Deep Learning Focus on? The diagnosis of acute coronary occlusion!'” Journal of Electrocardiology.
  • Spirito et al.: “Acute Coronary Occlusion in Patients With Non-ST-Segment Elevation Out-of-Hospital Cardiac Arrest,” J Am Coll Cardiol.
  • Guener et al.: “Clinical implication of totally occluded infarct-related coronary artery in non-ST-segment elevation myocardial infarction: the TOTAL-NSTEMI study,” Coronary Artery Disease.


  • Abusharekh M, Kampf J, Dykun I, et al.: “Acute coronary occlusion with vs. without ST-elevation: impact on procedural outcomes and long-term all-cause mortality,” EHJ – Quality of Care and Clinical Outcomes.
  • Smith SW, Meyers HP: “ST elevation is a poor surrogate for acute coronary occlusion. Let’s replace STEMI with Occlusion MI (OMI)!!” International Journal of Cardiology.

Podcast Transcription

Where to listen

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Cite this article as: Iain Beardsell, "Podcast – Occlusive Myocardial Infarction, ECGs and Artificial Intelligence with Steve Smith," in St.Emlyn's, July 10, 2024, https://www.stemlynsblog.org/podcast-chest-pain-and-ai-with-steve-smith/.

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