Dr. Smith's ECG Blog

DECEMBER 19, 2023

The commonest causes of MINOCA include: atherosclerotic causes such as plaque rupture or erosion with spontaneous thrombolysis, and non-atherosclerotic causes such as coronary vasospasm (sometimes called variant angina or Prinzmetal's angina), coronary embolism or thrombosis, possibly microvascular dysfunction. This is not the case.

E-9-1-1 118

E-9-1-1 Coronary ACS BLS 118

Dr. Smith's ECG Blog

OCTOBER 3, 2024

Coronaries were clean. ECG Features suggesting "Fake" As per Dr. Sam Ghali ( who sent us today's case ) — serial Troponins were clearly indicated since the patient presented to the ED. If a final test was perceived as "needed" — perhaps a normal coronary CT angiogram could have helped to avoid cardiac catheterization.

E-9-1-1 110

E-9-1-1 Coronary ALS ED 110

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. In this case, the EMS provider was routed to the urgent care facility.

STEMI 97

STEMI Coronary Defibrillator EMS 97

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 113

ACS ED Coronary EMS 113

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 91

Defibrillator STEMI Coronary ALS 91

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 66

STEMI Coronary ALS OR 66

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

OCTOBER 17, 2024

Written by Jesse McLaren Two patients in their 70s presented to the ED with chest pain and RBBB. The prehospital and ED computer interpretation was inferior STEMI: There’s normal sinus rhythm, first degree AV block and RBBB, normal axis and normal voltages. Coronaries were normal, as was serial troponin. Vitals were normal.

STEMI 73

STEMI Paramedic Coronary ED 73

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 98

Coronary ACS ED OR 98

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

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.

ACS 52

ACS Coronary STEMI ALS 52

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

Submitted by Dr. George Mastoras (Twitter @georgemastoras), written by Jesse McLaren It’s a busy day in the ED when you’re sent another ECG to sign off from a patient at triage. Here is the post shock ECG: Cardiology was called stat for ischemic VT, query SCAD vs thrombotic occlusion vs coronary vasospasm.

OR 66

OR STEMI ACS Coronary 66

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

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 60

STEMI Coronary CAD ED 60

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 79

ED OR ALS CAD 79

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 97

Coronary EMR STEMI Emergency Department 97

Dr. Smith's ECG Blog

OCTOBER 24, 2019

link] A 30 year-old woman was brought to the ED with chest pain. 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 is written by Brooks Walsh.

Coronary 52

Coronary CAD ACS STEMI 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. 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-9-1-1 107

E-9-1-1 Coronary EMS ED 107

Dr. Smith's ECG Blog

OCTOBER 12, 2024

EKG on arrival to the ED is shown below: What do you think? Preliminary findings documented in the cath lab were “Anterior STEMI and no significant coronary artery disease.” (!!!) or basilar ischemia. On my initial interpretation, the patient has normal sinus rhythm with a narrow QRS complex, and LVH. ng/mL and 0.10 J Electrocardiol.

STEMI 97

STEMI Coronary Emergency Department OR 97

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

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 90

STEMI Coronary Paramedic OR 90

Don't Forget the Bubbles

OCTOBER 7, 2024

However, vertical flow can result in myocardial injury secondary to coronary artery spasm. In: Walls RM, ed. Household supply in the UK and Australia is typically capped at 230v, so children get low-voltage injuries. Electrical Injuries. Chen P, Bukhman AK. Electrical and lightning injuries. Philadelphia, PA: Elsevier; 2023:chap 130.

ACS 80

ACS Life Support OR CPR 80

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 117

STEMI Emergency Department Coronary OR 117

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

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 STEMI 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

EMDocs

OCTOBER 30, 2023

” – Musings of an American ED resident in July 2022 when US healthcare was affected simultaneously by supply chain issues from GE Healthcare (contrast media) and Abbott Laboratories (Similac baby formula). 3 A study of CT use trends in the ED has shown increasing use of CTs by almost 60% from 2005 to 2013.

E-9-1-1 73

E-9-1-1 Emergency Department ALS ED 73

Dr. Smith's ECG Blog

FEBRUARY 13, 2023

If the patient only had these two ECGs recorded, it would have missed the transient time between them which were STEMI positive, and the patient would then have arrived at the ED as “serial ECGs STEMI negative." Accuracy of OMI findings versus STEMI criteria for diagnosis of acute coronary occlusion myocardial infarction. Meyers et al.

STEMI 52

STEMI Paramedic Coronary ALS 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

MAY 19, 2022

Written by Pendell Meyers, edits by Smith and Grauer A man in his late 20s with history of asthma presented to the ED with a transient episode of chest pain and shortness of breath after finishing a 4-mile run. At the time of evaluation in the ED, his symptoms were resolved. Ct coronary angiogram showed normal coronary arteries.

E-9-1-1 52

E-9-1-1 Coronary OR ED 52

Dr. Smith's ECG Blog

APRIL 22, 2022

Identifying patients with low risk for acute coronary syndrome without troponin testing: validation of the HEAR score. High-sensitivity cardiac troponin I at presentation in patients with suspected acute coronary syndrome: a cohort study. JAMA Intern Med 2019 9. Moumneh T, Sun BC, Baecker A, et al. Am J Med 2021 5.

E-9-1-1 52

E-9-1-1 STEMI ALS ED 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