Dr. Smith's ECG Blog

APRIL 18, 2024

The ECG is just a test: a Bayesian approach to acute coronary occlusion If a patient with a recent femur fracture has sudden onset of pleuritic chest pain, shortness of breath, and hemoptysis, the D-dimer doesn’t matter: the patient’s pre-test likelihood for PE is so high that they need a CT. A Bayesian approach to acute coronary occlusion.

STEMI 118

STEMI Coronary ALS CAD 118

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

Here is the post shock ECG: Cardiology was called stat for ischemic VT, query SCAD vs thrombotic occlusion vs coronary vasospasm. Cath lab was activated: There was no coronary artery disease, but there was spontaneous coronary artery dissection (SCAD) of the distal LAD, which was narrowed by 95%, and treated medically.

OR 66

OR STEMI ACS Coronary 66

EMS 12-Lead

APRIL 21, 2022

There is appreciable STE aVR with near-global STD that appropriately maximizes in Leads II and V5, and thus suggesting a circumstance of generic, diffusely populated, circumferential subendocardial ischemia versus occlusive coronary thrombus. [1] It’s judicious, then, to arrange for coronary angiogram. link] [1] Mirand, D.

Coronary 130

Coronary ALS OR ACS 130

Dr. Smith's ECG Blog

MAY 3, 2024

RBBB + LAFB in the setting of ACS is very bad. Some patients have baseline RBBB with LAFB, but in patients with likely ACS, these are associated with severe infarction with cardiac arrest, cardiogenic shock or impending shock. Patients with ACS and RBBB/LAFB usually have a left main vs. proximal LAD. Learning Points: 1.

ACS 114

ACS ED Coronary EMS 114

Don't Forget the Bubbles

OCTOBER 7, 2024

However, vertical flow can result in myocardial injury secondary to coronary artery spasm. This is supplied via alternating current (AC), increasing the risk of titanic contraction of skeletal muscle, leading to kids holding on to the electrical power source. AC and DC shocks may result in different injury patterns. Culnan, D.M.,

ACS 80

ACS Life Support OR CPR 80

ACEP Now

MARCH 14, 2024

Current can be alternating current (AC) or direct current (DC) with AC typically more dangerous as it is more likely to cause tetanic contractions and increase contact time with the electrical source. 2,3,5 Except for laundry or electrical car outlets (240 V AC), all U.S. household outlets are rated at 120 V AC.

Operating Room 52

Operating Room ACS Critical Care Coronary 52

Dr. Smith's ECG Blog

OCTOBER 24, 2019

The biphasic T wave is consistent with recent reperfusion of an occluded coronary artery supplying the inferior region. Here’s the angiogram of the RCA : No thrombus or plaque rupture in the RCA (or any coronary artery) was found. This MI wasn’t caused by a ruptured plaque of CAD - it was a coronary artery dissection of the RCA.

Coronary 52

Coronary CAD ACS STEMI 52

Dr. Smith's ECG Blog

MAY 13, 2020

Here is the EMS ECG: Obviously massive diffuse subendocardial ischemia, with profound STD and STE in aVR Of course this pattern is most often seen from etoliogies other than ACS. The case I presented in My Comment to that March 9, 2020 post showed a patient with this pattern — who on cath had no more than minimal coronary disease.

Coronary 52

Coronary ACS EMS ALS 52

REBEL EM

JANUARY 29, 2024

Click here for Direct Download of the Podcast Paper: Aykan AC et al. JACC Cardiovasc Interv 2018. PMID: 23102885 Aykan AC et al. Because the lungs receive 100% of cardiac output, it has been hypothesized that a lower dose of thrombolytic therapy may still be effective with a better safety profile [3][4]. Clin Exp Emerg Med 2023.

ALS 137

ALS ACS OR CPR 137

Dr. Smith's ECG Blog

JULY 31, 2018

Now you have ECG and troponin evidence of ischemia, AND ventricular dysrhythmia, which means this is NOT a stable ACS. Next day, t he patient was taken for an angiogram and found to have a reperfused LAD lesion with good flow that appeared to the angiographer as if it was a spontaneous coronary artery dissection.

Coronary 52

Coronary ACS STEMI OR 52

Dr. Smith's ECG Blog

SEPTEMBER 7, 2024

Eur Heart J 2018. No wall motion abnormality This shows that significant ACS can have ZERO WMA!! A comparison of electrocardiographic changes during reperfusion of acute myocardial infarction by thrombolysis or percutaneous transluminal coronary angioplasty. Lemkes et al. Full text link. Normal left ventricular cavity size.

STEMI 113

STEMI ACS Critical Care OR 113

EMS 12-Lead

APRIL 2, 2022

He reported a history of ischemic cardiomyopathy with coronary stent placement approximately 10 years prior, but could not recall the specific artery involved. Anecdotally, had there been symptoms unequivocally consistent with ACS then one could justifiably make the case for a potential D1 occlusion. Attached is the first ECG.

ALS 130

ALS STEMI Coronary OR 130

Dr. Smith's ECG Blog

MAY 8, 2023

Electrocardiographic Diagnosis of Acute Coronary Occlusion Myocardial Infarction in Ventricular Paced Rhythm Using the Modified Sgarbossa Criteria. Immediate ECG diagnosis of an acute coronary lesion resulting in occlusion myocardial infarction is critical in the modern reperfusion era. Annals of Emergency Medicine 2021.

STEMI 52

STEMI Coronary ED ACS 52

Dr. Smith's ECG Blog

NOVEMBER 14, 2023

We who know ischemic ECGs know that really when T-wave inversion is specific for coronary thrombosis that it indicates reperfusion of the artery, not active occlusion. For examples of this phenomenon — See My Comment in the February 14, 2018 — July 21, 2020 — and December 22, 2022 posts in Dr. Smith's ECG Blog ). Some patients do this.

E-9-1-1 107

E-9-1-1 Coronary EMS ED 107

Dr. Smith's ECG Blog

FEBRUARY 28, 2020

Some providers were worried about ACS because of this ECG. My answer alleviated their concern for ACS and no further workup was done for ACS. showed that , when T-waves are inverted in precordial leads, if they are also inverted in lead III and V1, then pulmonary embolism is far more likely than ACS. Kosuge et al.

E-9-1-1 52

E-9-1-1 ACS ALS OR 52

ECG & Echo Learning

OCTOBER 2, 2022

Below follows a drug manual for use in the CCU (coronary care unit), ICU (intensive care unit) or ER (emergency room). μg/kg/min + + + ++ Low dose dopamine stimulates D1 receptors and induces vasodilation in coronary, renal, cerebral and mesenteric vessels. Increases coronary blood flow. Coronary flow enhanced.

E-9-1-1 52

E-9-1-1 ALS Coronary Epinephrine 52

Dr. Smith's ECG Blog

AUGUST 17, 2022

V5, 6) is 97% specific for OMI in a patient population at high risk of ACS. The modest HS troponin elevation with lack of wall motion abnormality and excellent ejection fraction on Echo were consistent with Type-2 MI — confirming that the initial ECG did indeed give the false impression of acute coronary occlusion.

Coronary 52

Coronary ACS OR 52

Dr. Smith's ECG Blog

OCTOBER 24, 2018

The patient would not have been diagnosed with acute coronary syndrome and would not have had an angiogram, would have been discharged (or perhaps had a stress test, which would be negative), and would be at great risk of another event, possibly resulting in death or heart failure. Imagine if you had only recorded the 2nd ECG. Mokhtari et al.

E-9-1-1 52

E-9-1-1 STEMI ACS Coronary 52

Dr. Smith's ECG Blog

OCTOBER 3, 2018

When he showed it to me, I said "Ouch, looks like an acute coronary occlusion. no LBBB or paced rhythm), acute coronary occlusion MI (OMI) is diagnosed in approximately 75% of cases. Here is our abstract from SAEM 2018. What happened?" The medic recorded another 12-lead en route 13 minutes later: What do you think?

Coronary 52

Coronary STEMI Paramedic ALS 52

Dr. Smith's ECG Blog

OCTOBER 26, 2020

Coronary spasm causing massive current of injury with shark fin ECG. I would not expect ST-E to vanish in four beats with dissolving thrombus (also we know that the coronaries were clean). The patient was not experiencing any typical coronary chest pain at these short episodes of ST-E. I suspect LAD or LM.

Coronary 52

Coronary Defibrillator ACS CAD 52

Dr. Smith's ECG Blog

DECEMBER 15, 2023

Learning Points : Serial ECG are very valuable when it comes to identifying a dynamic process such as ACS. Eventually with more training the QoH will outperform any human in the detection of acute coronary occlusion. This patient’s OMI was identified early due to expert ECG interpretation.

ACS 60

ACS STEMI Coronary EMS 60

ECG & Echo Learning

JANUARY 18, 2023

This page summarises the most current recommendations for the management of acute coronary syndromes with persistent ST-segment elevations (i.e III A Primary percutaneous coronary intervention strategy Management Recommendation Level of evidence Primary PCI of the infarct related artery (IRA) is indicated.

STEMI 40

STEMI Coronary OR Defibrillator 40

Dr. Smith's ECG Blog

OCTOBER 6, 2018

The patient was in his 50s with history of hypertension, diabetes, seizure disorder, and smoking, but no known coronary artery disease. No patient should have to be "lucky" by having a positive troponin to be taken seriously as a possible acute coronary occlusion. 418 of these 1788 (23%) had acute coronary occlusion.

STEMI 52

STEMI Coronary ALS OR 52

Dr. Smith's ECG Blog

FEBRUARY 6, 2020

Whenever the only presenting symptom is syncope, without any other symptom, I am very skeptical that coronary occlusion (OMI) is the etiology. Abdominal pain can of course be a symptom of ACS, but it was brief and seemed to have resulted in a vasovagal event. It is certainly possible, but the pretest probability is very low.

ACS 52

ACS ED Coronary STEMI 52

Dr. Smith's ECG Blog

NOVEMBER 24, 2018

There was no ACS here. Discussion On this blog, I show a lot of ECGs that were sent to me and show subtle findings of OMI (acute coronary occlusion). And it turns out that this was the baseline ECG. However, the vast majority of ECGs that are sent to me are NOT occlusion, but mimics. There is a lot of upward concavity on the upstroke.

ACS 52

ACS OR Coronary 52

Dr. Smith's ECG Blog

NOVEMBER 26, 2018

The axiom of "type 1 (ACS, plaque rupture) STEMIs are not tachycardic unless they are in cardiogenic shock" is not applicable outside of sinus rhythm. This case represents the same physiologic event as OMI in terms of the result on the myocardium, therefore with identical ECG features, however there may not be ACS!

STEMI 52

STEMI ACS CAD OR 52

Dr. Smith's ECG Blog

MARCH 6, 2019

She did not receive any opioids (which would mask her pain without affecting any underlying ACS). The Portable Programmable Microprocessor-Driven Real-Time 12-Lead Electrocardiographic Monitor: A Preliminary Report of a New Device for the Noninvasive Detection of Successful Reperfusion or Silent Coronary Reocclusion. Blondheim et al.

STEMI 52

STEMI ALS ACS OR 52

EMDocs

JANUARY 6, 2024

3,10 Coronary Allograft Vasculopathy Nicknamed “The Achilles Heel of Heart Transplantation,” this accounts for the majority of patient mortality in the 5-10 year range. 10 It affects the whole length of the vessel and all layers of the coronary vasculature rather than just the intima, which is seen in non-transplant atherosclerosis.

EMS 63

EMS E-9-1-1 ACS Coronary 63

EMDocs

JANUARY 20, 2024

The catheterization lab is activated, but catheterization shows no coronary artery occlusion. ECG shows ST-segment elevation in V3-V6 only with depression in aVR. Initial troponin is mildly elevated. On further questioning, the patient denies recent illness but does mention that her daughter passed away in a car accident yesterday.

E-9-1-1 74

E-9-1-1 EMS Coronary ACS 74

Dr. Smith's ECG Blog

NOVEMBER 3, 2017

Here is a video lecture of subtle LAD occlusion: One hour lecture on Subtle ECG Findings of Coronary Occlusion The 3-variable formula comes from this paper: Smith SW et al. Am J Cardiol 2018; 122(8):1303-1309. He went for Coronary bypass (CABG). Instructions for using free subtleSTEMI iPhone app for the 3-variable formula.

STEMI 52

STEMI Coronary OR ALS 52

EMDocs

NOVEMBER 4, 2024

54 It is vital to consider dangerous epigastric pain mimickers like acute coronary syndrome (ACS), hepatobiliary disease, or pancreatitis. 2018 Nov;19(6):952-960. Epub 2018 Sep 10. Comparison of factors associated with atypical symptoms in younger and older patients with acute coronary syndromes. West J Emerg Med.

ED 98

ED E-9-1-1 Emergency Department ALS 98