Dr. Smith's ECG Blog

JULY 7, 2024

First trop was 7,000ng/L (normal 25% of ‘Non-STEMI’ patients with delayed angiography have the exact same pathology of acute coronary occlusion. The new ACC expert consensus explains that: “STEMI ECG criteria on a standard 12-lead ECG alone will miss a significant minority of patients who have acute coronary occlusion. Take home 1.

STEMI 70

STEMI Coronary ALS OR 70

Dr. Smith's ECG Blog

JUNE 21, 2023

Below is the version standardized by PM Cardio app Meyers interpretation: Findings are specific for posterior (and also likely inferior) wall transmural acute infarction, most likely due to acute coronary occlusion (OMI). Clinical Cardiology 2019. Most OMI have a peak Troponin T over 1000 ng/L [reference: Baro R et al.

STEMI 96

STEMI Coronary Defibrillator EMS 96

Dr. Smith's ECG Blog

JULY 21, 2024

It shows a proximal LAD occlusion, in conjunction with a subtotally occluded LMCA ( Left Main Coronary Artery ). Upon contrast injection of the LMCA, the patient deteriorated, as the LMCA was severely diseased and flow to all coronary arteries ( LAD, LCx and RCA ) was compromised. He was taken immediately to the cath lab.

Defibrillator 116

Defibrillator Coronary ALS STEMI 116

Dr. Smith's ECG Blog

JUNE 27, 2024

The proof of this is that only 5% of patients enrolled had acute coronary occlusion. Coronary Angiography after Cardiac Arrest without ST-Segment Elevation. N Engl J Med [Internet] 2019;Available from: [link] Should all patients with shockable arrest be taken to angiography regardless of STEMI or No STEMI? 5% vs. 58%!!

Defibrillator 94

Defibrillator STEMI Coronary ALS 94

Dr. Smith's ECG Blog

JUNE 14, 2024

He underwent coronary angiography which showed severe multivessel disease, and he agreed to proceed with workup for CABG. The September 27, 2019 post — for the Rowlands & Moore article with the above-noted formulas for recognizing the “culprit” extremity. The September 22, 2019 post — intermittent ST-T wave artifact.

Defibrillator 78

Defibrillator ALS Coronary OR 78

Dr. Smith's ECG Blog

APRIL 25, 2023

But the stuttering pain and sudden onset suggest acute coronary occlusion (Occlusion MI, or OMI). Cath lab activation by the ED and I agree with coronary angiography emergently." Result: no angiographically significant obstructive coronary artery disease. Smith and Meyers to diagnose both obvious (STEMI) and subtle OMI.

Coronary 52

Coronary STEMI ALS OR 52

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

Hgb 11g/dL (110g/L) and leukocytosis, and a mildly elevated troponin (36 ng/L, with normal 1mm STE in aVR due to ACS will require coronary artery bypass surgery for revascularization, the infarct artery is often not the LM, but rather the LAD or severe 3-vessel disease. Incidence of an acute coronary occlusion. link] Harhash AA et al.

Coronary 52

Coronary ACS STEMI ALS 52

Dr. Smith's ECG Blog

FEBRUARY 16, 2020

Shark Fin has also been called: " Giant R-wave " " Triangular QRS-ST-T waveform " Usually shark fin is in one coronary distribution and represents massive ST elevation that is as high as the peak of the R-wave and therefore fuses the R-wave and ST segment. She was taken to the cath lab and her coronaries were clean!!

Coronary 52

Coronary STEMI 52

Dr. Smith's ECG Blog

JUNE 8, 2023

According to the STEMI paradigm, the patient doesn’t have an acute coronary occlusion and doesn't need emergent reperfusion, so the paramedics can bring them to the ED for assessment, without involving cardiologists. STEMI criteria, and automated interpretations based on it, will miss acute coronary occlusion. Eur Heart J 2019 5.

STEMI 62

STEMI Coronary Paramedic ALS 62

EMS 12-Lead

APRIL 14, 2022

It should be emphasized here that this is a presentation of high-pretest probability for Acute Coronary Syndrome (ACS). Utility of the history and physical examination in the detection of Acute Coronary Syndromes in emergency department patients. Past medical history included HTN, HLD, and MI 10 years prior. link] [1] Zachary et al.

ACS 130

ACS Paramedic Coronary ALS 130

EMS 12-Lead

AUGUST 22, 2022

The coronary angiogram revealed no critical stenosis, or acute plaque ulceration. Takotsubo should be a diagnosis of exclusion after angiography reveals no obstructive coronary disease, and repeat Echo displays left ventricular recovery. Furthermore, pertinent electrolyte values (e.g. potassium) were within normal parameter.

E-9-1-1 130

E-9-1-1 Coronary ALS ICU 130

Dr. Smith's ECG Blog

JANUARY 1, 2024

His medical history includes hypertension, a decade-long battle with diabetes, ischemic heart disease, a coronary bypass graft surgery ten years ago, a diagnosis of congestive heart failure for the last five years, and a prior ICD implantation five years ago.

Coronary 99

Coronary EMR STEMI Emergency Department 99

Dr. Smith's ECG Blog

JULY 31, 2020

Their OMI Manifesto details how use of standard STEMI criteria results in an unacceptable level of inaccuracy, in which an estimated 25-30% of acute coronary occlusions are missed! The more leads in a given lead area that show hyperacute changes — the greater the concern for acute OMI.

STEMI 52

STEMI Coronary EMR ALS 52

EMS 12-Lead

APRIL 8, 2022

Cardiology admitted him for observation with plans for next-day coronary angiogram. Unfortunately, due to the patient’s abrupt exodus from the PCI center – without benefit of coronary angiogram, or echo, for example – the disposition will forever remain unknown. [1] The peak Troponin I confirmed myocardial infarction. (A 1] Driver, B.

STEMI 130

STEMI ALS Coronary CAD 130

Dr. Smith's ECG Blog

MAY 13, 2020

Smith presented results from a 2019 article by Harhash et al, that confirm how the ECG pattern shown in Figure-1 does not represent acute LMain occlusion — but rather the differential diagnosis that I show above. Today’s Post by Dr. Smith adds to our knowledge of this syndrome.

Coronary 52

Coronary ACS EMS ALS 52

Dr. Smith's ECG Blog

JANUARY 3, 2022

It was a 60yo with a history of stents to the circumflex and right coronary arteries, who presented with 9 hours of fluctuating central chest pain. This is step 4 : relying on the first troponin level to rule out acute coronary occlusion. 4] CT revealed no dissection but extensive coronary atherosclerosis.

STEMI 52

STEMI Coronary ALS ACS 52

Dr. Smith's ECG Blog

JUNE 19, 2024

The ED provider ordered a coronary CT scan to assess the patient for CAD. The patient was taken emergently to the cath lab for a pericardiocentesis instead of a coronary angiogram. A troponin T was drawn at 1229 and resulted slightly elevated at 23 ng/L (URL for men in this assay is 15 ng/L).

STEMI 63

STEMI Coronary CAD ED 63

Emergency Medicine Ireland

OCTOBER 30, 2023

This vasoconstriction affects pretty much all the vasculature including things like the coronaries (not so good) but does seem to spare the pulmonary arteries meaning it may be good in those with pulmonary hypertension. Nagendran 2019 in CCM. Intens Care Med 45 , 844–855 (2019). What other receptors is it worth knowing about?

Critical Care 52

Critical Care ALS Coronary ICU 52

Dr. Smith's ECG Blog

MAY 23, 2023

I have here 38 cases of "Computer Normal" ECGs which were critically abnormal and the vast majority are missed acute coronary occlusions (Missed Acute OMI) and most were recognized by the physician. We wrote this Editorial in the Journal of Electrocardiology in 2019. Litell JM, Meyers HP, Smith SW.

STEMI 88

STEMI Coronary Paramedic OR 88

Dr. Smith's ECG Blog

NOVEMBER 5, 2023

By Magnus Nossen, edits by Grauer and Smith The patient is a 70-something female with DMII, HTN and an extensive prior history of coronary artery disease and myocardial infarctions. PLUS — Today's patient is an older woman with known severe coronary disease who presented with new chest pain. She's had multiple PCI procedures.

Coronary 103

Coronary OR ALS 103

Dr. Smith's ECG Blog

FEBRUARY 10, 2023

Because of the importance of this entity — we continue to periodically review it in cases we present ( See the May 2, 2019 post — among many others ). Among these patterns are de Winter T waves — which is the reason Dr. Smith selected the ECG in today's case. D e W inter T Waves : In 2008 — Robert J. de Winter and colleagues ( Drs.

ALS 52

ALS STEMI Coronary OR 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 such exceptions — See My Comment in the January 9, 2019 — August 22, 2020 — and June 30, 2023 posts in Dr. Smith's ECG Blog ). Some patients do this.

E-9-1-1 110

E-9-1-1 Coronary EMS ED 110

Dr. Smith's ECG Blog

OCTOBER 18, 2023

6] Among 394 emergency department Code STEMI patients with acute culprit lesion requiring coronary interpretation, 16 (4.1%) presented with an ECG labeled ‘normal’ or ‘otherwise normal’ by computer interpretation. 2019 ; 54 : 79 - 81. have published a number of warnings about the previous reassuring studies.[4,5] Am J Emerg Med.

STEMI 121

STEMI Emergency Department Coronary OR 121

EMS 12-Lead

MAY 8, 2022

Cardiology was consulted, who advised to surveil a metabolic process as this did not strike them as acute coronary syndrome. No calcium was administered during pre-hospital transport. The following ECG was captured upon arrival at the receiving ED. The serum K returned 8.7, along with a pH 6.94, and an HCO3 of 5. McCance, K.

STEMI 130

STEMI ED EMS Firefighter 130

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

And so it is wise to look at the coronary arteries. This ECG certainly looks like myocarditis, and was due to myocarditis, but missing acute coronary occlusion is not acceptable. In a series of 18 patients with COVID and ST elevation, 8 were diagnosed with STEMI, 6 of whom had an angiogram and it showed obstructive coronary disease.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

Dr. Smith's ECG Blog

NOVEMBER 1, 2022

The 50-something patient with history of coronary stenting and slightly reduced LV ejection fraction. which would suggest reduced rates of major adverse cardiac events with coronary artery bypass grafting." On the other hand, stable EKG over an hour in the setting of ongoing acute coronary syndrome is again unusual.

Overdose 52

Overdose OR Coronary ACS 52

Dr. Smith's ECG Blog

APRIL 15, 2019

[link] An angiogram was done: It showed no culprit and no coronary disease, but did show a myocardial bridge in the mid LAD. An excellent review of myocardial bridging, with full text: [link] Myocardial bridging is when the coronary artery, usually the LAD, dives into the myocardium.

Coronary 52

Coronary STEMI OR ED 52

Dr. Smith's ECG Blog

JUNE 28, 2019

For coronary anatomy, see here: [link] This is the post intervention ECG: All ST Elevation is gone (more proof that it was all a result of ischemia) Formal Echo: Normal estimated left ventricular ejection fraction - 55%. K EY P oints : This patient has known coronary disease. It was stented. Compare with an old ECG.

Coronary 52

Coronary ACS ED OR 52

Dr. Smith's ECG Blog

MARCH 31, 2023

The 2 clinical areas of most potential benefit to emergency care from computerized interpretations are: i ) Cardiac arrhythmias; and , ii ) Rapid detection of acute coronary O cclusion ( ie, detection of acute O MI ) in cases for which easily recognizable STEMI-criteria are not present. What About the Initial ECG?

STEMI 52

STEMI Coronary OR ED 52

Dr. Smith's ECG Blog

MARCH 9, 2023

Relationship between an in-farct related artery, acute total coronary occlusion, and mortality in patients with ST-segment and non-ST-segment myocardial infarction. By way of review — I i llustrate the ECG finding of T-QRS-D below in Figure-2 , which I've excerpted from My Comment in the November 14, 2019 post in Dr. Smith's ECG Blog.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

Dr. Smith's ECG Blog

DECEMBER 10, 2019

But young people do have MI, due to anomalous coronary arteries, coronary artery dissection, Kawasaki dz, even atherosclerotic plaque rupture, and other etiologies. When it comes to coronary occlusion, you can't just say: "Well, myocarditis is more likely, therefore I will not investigate further. You have to be CERTAIN.

E-9-1-1 52

E-9-1-1 Coronary OR ACS 52

Dr. Smith's ECG Blog

NOVEMBER 13, 2022

Take home messages: Any coronary occlusion may present with vague symptoms, but when ECG is clear, there should not be any suspicion. 2019 Apr;21(5):253-258. Fortunately, peak troponin was only 1090 ng/L and next day EF was 45-50% with apical and mid anterior hypokinesia. ECG hardly ever tells lies! Anatol J Cardiol. 2019.09465.

EMR 52

EMR Coronary OR STEMI 52

Dr. Smith's ECG Blog

DECEMBER 13, 2019

(acute MI, not pericarditis) You Diagnose Pericarditis at your Peril (at the Patient's Peril!) --Acute MI misdiagnosed as pericarditis. == MY Comment by K EN G RAUER, MD ( 12/13/2019 ): == I LOVE this post — as it explores the important decision-making process associated with the ED diagnosis of a cute P ericarditis.

E-9-1-1 52

E-9-1-1 ACS Coronary CAD 52

Dr. Smith's ECG Blog

FEBRUARY 4, 2022

I have here 30 cases of "Computer Normal" ECGs which were critically abnormal and the vast majority are missed acute coronary occlusions (Missed Acute OMI) and most were recognized by the physician. We wrote this Editorial in the Journal of Electrocardiology in 2019. Litell JM, Meyers HP, Smith SW.

STEMI 52

STEMI Coronary Emergency Department OR 52

Dr. Smith's ECG Blog

APRIL 29, 2023

Clinicallly — this would be consistent with the less-than-total coronary occlusion seen on cath. I interpreted these ST-T wave changes as subtle findings suggesting reperfusion T waves ( which in the posterior wall distribution — manifests as increased T wave amplitude in anterior leads ).

Critical Care 52

Critical Care Coronary ED OR 52

REBEL EM

MARCH 30, 2023

The TOMAHAWK (Desch 2021), COACT (Abella 2019), and PEARL (Lemkes 2019) trials examined patients with OHCA without ST elevation with a shockable rhythm, and investigators found no difference in delayed versus emergency angiogram. Early coronary angiography and survival after out-of-hospital cardiac arrest. P., & Cariou, A.

Coronary 63

Coronary CPR OR ICU 63

Dr. Smith's ECG Blog

APRIL 15, 2020

An elderly woman with history of coronary disease presented with CP and SOB and hypotension by EMS. Angiogram: Severe coronary artery calcification Moderate to severe distal small vessel disease mainly seen in RPL1, 2 Otherwise, Mild plaque, no angiographically significant obstructive coronary artery disease.

Coronary 52

Coronary ED OR Overdose 52