Dr. Smith's ECG Blog

DECEMBER 11, 2023

For the same reason, you should not delay coronary angiography because pain resolves with morphine. Smith : As Willy states, ACS with persistent symptoms is a guideline recommended indication for ＜2 hour angio (both ACC/AHA and ESC). But pain is a critical signal for urgency in the context of acute coronary syndrome. Worrall, C.,

E-9-1-1 121

E-9-1-1 ACS Coronary STEMI 121

Dr. Smith's ECG Blog

APRIL 9, 2024

ACS then becomes less likely. Before the lab values returned this patient had a n emergent coronary CT angiogram done that ruled out CAD. A false positive cath lab activation is also off course acceptable for this diagnosis if you cannot get an emergent coronary CT angiogram. There are no coronary stenoses.

Coronary 91

Coronary CAD ACS OR 91

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 117

STEMI Coronary ALS CAD 117

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.

Coronary 130

Coronary ALS OR ACS 130

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

DECEMBER 27, 2023

Note that as many as 7% of patients with acute coronary syndrome have chest pain reproducible on palpation [Lee, Solomon]. which reduces the pre-test probability of acute coronary syndrome by less than 30% [McGee]. Chest pain reproducible on palpation does not rule out acute coronary syndrome. Guagliumi, G., Iwaoka, R.

E-9-1-1 116

E-9-1-1 OR Coronary ACS 116

EMS 12-Lead

JUNE 1, 2022

Such findings would normally suggest primary ischemia with concomitant surveillance of coronary occlusion, but these ST/T changes might very well be secondary to the Escape mechanism at hand. Evaluation of T-wave morphology in patients with left bundle branch block and suspected acute coronary syndrome. 4] Dodd, K. 5] Isnard, R.

Coronary 130

Coronary ALS Firefighter ACS 130

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

In our opinion it should not be given in ACS unless you are committed to the cath lab. Learning Point: Any NSTEMI patient with active ongoing ACS symptoms refractory to medical management is supposed to go to the cath lab within 2 hours if available, per all guidelines in world, regardless of ECG findings. 2009;95:1701–1706.

ACS 82

ACS Coronary ALS CAD 82

Dr. Smith's ECG Blog

AUGUST 11, 2024

Despite many ECG signs of OMI being missed the door-to-cath time was still fast, because all the healthcare providers were focused on the pathology of acute coronary occlusion and not were distracted by the lack of STEMI criteria. Start using the terms acute coronary occlusion and occlusion MI.

STEMI 74

STEMI Paramedic Coronary EMS 74

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

References: 1) See this study showing an association between morphine and mortality in Non-STE-ACS: Meine TJ, Roe M, Chen A, Patel M, Washam J, Ohman E, Peacock W, Pollack C, Gibler W, Peterson E. Association of intravenous morphine use and outcomes in acute coronary syndromes: Results from the CRUSADE Quality Improvement Initiative.

E-9-1-1 78

E-9-1-1 ACS STEMI Coronary 78

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 STEMI 52

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

The fire department, who operate at an EMT level in this municipality, arrived before us and administered 324 mg of baby aspirin to the patient due to concern for ACS. Such cases are classified as MINOCA (Myocardial Infarction with Non-Obstructed Coronary Arteries). An angiogram is a "lumenogram;" most plaque is EXTRALUMINAL!!

Emergency Department 52

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

Dr. Smith's ECG Blog

JULY 27, 2023

I did not think it was due to ACS, but we ordered an ED ECG immediately: What do you think? But in this case the clinical scenario is not right for acute ACS with OMI, and there is very high voltage, and the patient is very young, (though beware of young patients , even 29 year olds!! I was not worried for a coronary etiology.

Coronary 52

Coronary ACS Naloxone Plasma 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

APRIL 8, 2022

The ECG is diagnostic for acute transmural infarction of the anterior and lateral walls, with LAD OMI being the most likely cause (which has various potential etiologies for the actual cause of the acute coronary artery occlusion, the most common of which is of course type 1 ACS, plaque rupture with thrombotic occlusion).

STEMI 52

STEMI Coronary ACS ED 52

Dr. Smith's ECG Blog

JANUARY 9, 2024

Ischemia from ACS causing the chest discomfort, with VT another consequence (or coincidence)? Cardioversion will address the rhythm problem immediately, also if the chest discomfort subsides when SR is restored, ischemia from ACS becomes much less likely. In either case, prompt cardioversion is indicated.

Coronary 98

Coronary ACS ED OR 98

Dr. Smith's ECG Blog

MAY 31, 2023

-See this study showing an association between morphine and mortality in ACS: Use of Morphine in ACS is independently associated with mortality, at odds ratio of 1.4. Association of intravenous morphine use and outcomes in acute coronary syndromes: Results from the CRUSADE Quality Improvement Initiative. Abstract 556.

STEMI 81

STEMI Coronary ACS OR 81

Dr. Smith's ECG Blog

JANUARY 6, 2023

Immediate and early percutaneous coronary intervention in very high-risk and high-risk Non-STEMI patients. Smith comment: We have shown that use of opiates is associated with worse outcomes in ACS: Bracey, A. Opioids in ACS may reduce the pain score, but do not provide reperfusion for ongoing ACS. Lupu L, et al.

ACS 52

ACS Coronary ICU STEMI 52

Dr. Smith's ECG Blog

JANUARY 31, 2020

But it does prove that the patient has coronary disease and makes the probability that his chest pain is due to ACS very very high. It is proven better than angiography alone in stable angina , and also has been shown to improve decisions on stenting non-culprit lesions in ACS. It could be acute, though probably is not.

ED 52

ED Coronary ACS CAD 52

Dr. Smith's ECG Blog

AUGUST 19, 2023

But because the patient had no chest pain or shortness of breath, it was not deemed to be from ACS. They were less likely to have STEMI on ECG, and more likely to be initially diagnosed as non-ACS. Dialysis patients have a high rate of ACS without chest pain and high rate of delayed diagnosis and delayed reperfusion 2.

STEMI 86

STEMI ACS OR ALS 86

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

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

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

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

OCTOBER 2, 2021

After rethinking the case, he remained concerned about ACS and subsequently performed a point-of-care ultrasound in order to evaluate for regional wall motion abnormality. There is no age cut-off for ACS. Immediately after the second ECG was performed, the patient's pain resolved completely. 1] Wereski, R., Chapman, A. 1] Wereski, R.,

OR 52

OR ACS STEMI Coronary 52

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

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

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 12, 2022

You must understand this and the dynamic nature of ACS to provide excellent care for such patients. One year later: EKG#5 (one year later) Inferior Q waves persist, as do inferior T wave inversions. Learning Points: The ECG can pass through normal or near-normal on its way from occlusion to reperfusion, or vice versa.

OR 52

OR ACS STEMI Coronary 52

Dr. Smith's ECG Blog

AUGUST 28, 2020

A fixed stenosis in that other artery, especially in the context of hypotension from the occlusion of the first coronary artery, can lead to ischemia and very poor LV function and worsening shock. Cardiogenic shock and ACS is an indication for the cath lab, even if you don't think there is OMI. Sotalol prolongs the QT 7.

Coronary 52

Coronary ACS OR STEMI 52

Dr. Smith's ECG Blog

OCTOBER 11, 2020

And a complication. == MY Comment by K EN G RAUER, MD ( 10/11/2020 ): == It cannot be stated any clearer than what Dr. Meyers states above. PEARL #3: I’ve described the Mirror Test on a number of occasions in Dr. Smith’s ECG Blog ( Please see My Comment in the September 21, 2020 post). Is that normal?

STEMI 52

STEMI ACS OR Coronary 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

JANUARY 28, 2023

This ECG is pathognomonic, regardless of any information, prior ECG, etc available: it means the LAD territory is undergoing immediate and hyperacute full thickness infarction, with the most likely etiology being type 1 ACS. Concerning for ongoing injury, concerning for the "No Reflow" phenomenon. No peak troponin was measured.

STEMI 52

STEMI ED ACS Coronary 52

Dr. Smith's ECG Blog

AUGUST 13, 2020

This suggests that it is not an acute coronary syndrome." "His When there is tachycardia, you should doubt the diagnosis of ACS unless it is: a) massive MI with cardiogenic shock and thus poor LV function and poor stroke volume, b) in a patient with previous poor LV function c) combined with other acute pathology causing tachycardia 3.

Critical Care 52

Critical Care OR ACS STEMI 52

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

EMDocs

NOVEMBER 4, 2024

54 It is vital to consider dangerous epigastric pain mimickers like acute coronary syndrome (ACS), hepatobiliary disease, or pancreatitis. Epub 2020 Oct 31. Epub 2020 Oct 31. 2020 Apr/Jun;42(2):96-102. 2020 Jul;95(7):E160-E163. Epub 2020 May 1. Pain can be improved or exacerbated with meals.

ED 98

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