Dr. Smith's ECG Blog

JULY 7, 2024

They arrived in the ED 30 minutes later to meet the cardiology team, where an ECG was repeated: Again no STEMI criteria, and there has been improvement in the deWinter and swirl pattern. First trop was 7,000ng/L (normal 25% of ‘Non-STEMI’ patients with delayed angiography have the exact same pathology of acute coronary occlusion.

STEMI 70

STEMI Coronary ALS OR 70

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. paramedic transportation to the ED as “chest pain, STEMI negative” 2. Eur Heart J 2019 5. Take home 1.

STEMI 63

STEMI Coronary Paramedic ALS 63

Dr. Smith's ECG Blog

JUNE 27, 2024

Here was his initial ED ECG: Formal interpretation by interventional cardiologist: There is "Non-diagnostic" ST Elevation in V2-V4 and aVL. The proof of this is that only 5% of patients enrolled had acute coronary occlusion. Coronary Angiography after Cardiac Arrest without ST-Segment Elevation. This study failed to do so.

Defibrillator 95

Defibrillator STEMI Coronary ALS 95

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

EMS 12-Lead

MAY 8, 2022

This is critical for the EMS provider, or ED clinician, as identification of Grade I ischemia (aka, HATW’s) addresses the culprit lesion at the earliest opportunity with excellent downstream prognosis for the patient. [2] The following ECG was captured upon arrival at the receiving ED. The ED resulted an 8.7 An ECG is recorded.

STEMI 130

STEMI ED EMS Firefighter 130

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

Smith: If this is ACS (a big if), t his is just the time when one should NOT use "upstream" dual anti-platelet therapy ("upstream" means in the ED before angiography). Diffuse ST depression with ST elevation in aVR: Is this pattern specific for global ischemia due to left main coronary artery disease? Am J Med 2019, 132(5):622-630.

Coronary 52

Coronary ACS STEMI ALS 52

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. Chou's Electrocardiography in Clinical Practice, 6th ed. link] [1] Zachary et al.

ACS 130

ACS Paramedic Coronary ALS 130

Dr. Smith's ECG Blog

JUNE 19, 2024

Case An 82 year old man with a history of hypertension presented to the ED with chest pain at 1211. The ED provider ordered a coronary CT scan to assess the patient for CAD. His pain suddenly became much worse in the ED and he became acutely diaphoretic, dizzy, and hypotensive. There is pericardial tamponade.

STEMI 63

STEMI Coronary CAD ED 63

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. Chou’s Electrocardiography in Clinical Practice (6th ed). Pacing Clin Electrophysiol.,

E-9-1-1 130

E-9-1-1 Coronary ALS ICU 130

EMS 12-Lead

APRIL 8, 2022

1] Here is the admitting ED ECG after cancellation of Code STEMI. The patient continued to verbalize cessation of symptoms while in the ED. Cardiology admitted him for observation with plans for next-day coronary angiogram. However, in this context (i.e. V2 – in the final EMS ECG the ST segment was baseline. 1] Driver, B.

STEMI 130

STEMI ALS Coronary CAD 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 100

Coronary EMR STEMI Emergency Department 100

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. Here is the first ED ECG recorded, now pain free after sublingual Nitro: There is what appears to be a reperfusion T-wave in I and aVL.

E-9-1-1 111

E-9-1-1 Coronary EMS ED 111

Dr. Smith's ECG Blog

MAY 23, 2023

But the paramedic and the ED physician in this case did not subscribe to this idea. 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. Litell JM, Meyers HP, Smith SW.

STEMI 89

STEMI Coronary Paramedic OR 89

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] minutes).

STEMI 122

STEMI Emergency Department Coronary OR 122

Dr. Smith's ECG Blog

MAY 13, 2020

Here is the ED ECG on arrival: Less STE/STD Provider's Clinical Impression: "findings concerning for myocardial infarction, likely proximal LAD or Left main." 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

Dr. Smith's ECG Blog

JANUARY 3, 2022

A prospective validation of STEMI criteria based on the first ED ECG found it was only 21% sensitive for Occlusion MI, and disproportionately missed inferoposterior OMI.[1] A prospective validation of STEMI criteria based on the first ED ECG found it was only 21% sensitive for Occlusion MI, and disproportionately missed inferoposterior OMI.[1]

STEMI 52

STEMI Coronary ALS ACS 52

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

This is a 30-something healthy patient presented with COVID pneumonia who presented to the ED. 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. He was moderately hypoxic. Angiogram was negative.

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

Here was his initial ED ECG: There is sinus tachycardia at a rate of about 140 There is profound ST Elevation across all precordial leads, as well as I and aVL. link] An angiogram was done: It showed no culprit and no coronary disease, but did show a myocardial bridge in the mid LAD.

Coronary 52

Coronary STEMI OR ED 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

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%. T he C ASE : The patient is a 60-something who presented to the ED with n ew- o nset c hest p ain. It was stented.

Coronary 52

Coronary ACS ED OR 52

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. Here is her ED ECG: Here is the ED physician's interpretation: IMPRESSION UNCERTAIN REGULAR RHYTHM, wide complex tachycardia, likely p-waves. The patient was given a small dose of etomidate and electrically cardioverted in the ED.

Coronary 52

Coronary ED OR Overdose 52

Dr. Smith's ECG Blog

APRIL 29, 2023

A 50-something with no previous cardiac history and no risk factors presented to the ED with acute chest pain (pressure) that radiated to the left arm. The cardiology fellow came to the ED. Clinicallly — this would be consistent with the less-than-total coronary occlusion seen on cath. There is ST depression in V1-V3.

Critical Care 52

Critical Care Coronary ED OR 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 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

SEPTEMBER 21, 2022

A 40-something woman with diabetes and peripheral vascular disease who frequently needs the ED for chronic pain called 911 for sudden severe chest pain. Because of this, it was very difficult to record an ED ECG, but eventually it became possible: What do you think? The patient was very agitated and could not hold still.

STEMI 52

STEMI ED Coronary OR 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

AUGUST 26, 2019

The patient went emergently to the cath lab, where all coronary arteries were found to be normal. Note: Normal coronary arteries at the time of cath of course does not rule out the possibility of OMI. If I had known there was no definite chest pain or pressure this would have been slightly more confident.

STEMI 52

STEMI Coronary OR ED 52

Dr. Smith's ECG Blog

APRIL 24, 2020

Here was his ED ECG, which was identical to the prehospital ECG. The cath lab was not activated in the prehospital setting in this case — despite a prehospital tracing identical to the initial ECG in the ED , that I have reproduced for clarity in Figure-1. He did not get prehospital activation. What do you think?

STEMI 52

STEMI Coronary ED OR 52

Dr. Smith's ECG Blog

MAY 3, 2024

But this time the Queen gets it wrong (thinks it is not OMI): There were runs of VT: Tha patient arrived in profound shock and had an ED ECG: Now there is some evolution to include the ST elevation (rather than ST depression) in V4-V6. Figure-1: I've labeled the initial EMS ECG and the 1st 12-lead tracing done on arrival in the ED.

ACS 118

ACS ED Coronary EMS 118

Dr. Smith's ECG Blog

JULY 11, 2019

Cardiology was called and the patient was taken for urgent catheterization with the time from ED arrival to cath about 1 hour and 45 minutes. When in doubt, record serial ECGs and watch out for signs of ischemia despite medical management. == Comment by K EN G RAUER, MD ( 7/11/2019 ): == Our thanks to Drs.

STEMI 52

STEMI ACS CAD ED 52

Dr. Smith's ECG Blog

APRIL 20, 2019

STE in V1 with STD in V6 in the presence of a normal QRS complex is another piece of evidence consistent with LAD occlusion. == Comment by K EN G RAUER, MD ( 4/20/2019 ): == With this case — Dr. Meyers addresses a common theme of this ECG Blog = HOW LONG to wait for your OMI ECG to show a STEMI?

STEMI 52

STEMI EMS OR Coronary 52

Dr. Smith's ECG Blog

JANUARY 9, 2024

The patient is an older woman with known coronary disease and an ICD-Pacemaker implanted because of a history of VT ( V entricular T achycardia ). This patient presented to the ED “after a couple of days of chest discomfort”. Remember that this patient presented to the ED “after a couple of days of chest discomfort”.

Coronary 102

Coronary ACS ED OR 102

Dr. Smith's ECG Blog

JUNE 2, 2023

Despite otherwise normal vital signs, she was appropriately triaged to the critical care area of the ED. They are rare and hard to find in normal practice in the ED. She denied chest pain and denied feeling any palpitations, even during her triage ECG: What do you think? Here is an explanation of the importance of leads V1 and V2.

ED 78

ED OR ALS CAD 78

Dr. Smith's ECG Blog

SEPTEMBER 7, 2020

A 30-something was in the ED for some minor trauma when he was noted to have a fast heart rate. Not all forms of idiopathic VT are predictable based on their ECG appearance ( Anderson et al, 2019 ). He acknowledged that he had palpitations. but only when asked. He had a history heavy alcohol use. Blood pressure was normal (109/83).

E-9-1-1 52

E-9-1-1 ALS OR Coronary 52

Dr. Smith's ECG Blog

MAY 16, 2023

Emergent CT coronary angio also likely has a role in such cases. Like they would for any other acute arterial occlusion syndrome (such as suspicion of acute large vessel stroke), they take the patient across the hall and perform an immediate CT (coronary) angiogram, showing patent coronaries.

Coronary 52

Coronary STEMI ED OR 52

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

Hospital Course The patient was taken emergently to the cath lab which did not reveal any significant coronary artery disease, but she was noted to have reduced EF consistent with Takotsubo cardiomyopathy. Such cases are classified as MINOCA (Myocardial Infarction with Non-Obstructed Coronary Arteries). It can only be seen by IVUS.

Emergency Department 52

Emergency Department E-9-1-1 Coronary STEMI 52