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 119

STEMI Coronary ALS CAD 119

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. 2] Aslanger, E., 3] deWinter, R.

Coronary 130

Coronary ALS OR ACS 130

Dr. Smith's ECG Blog

APRIL 22, 2024

EKG from triage: Here is his previous ECG: Normal ST Elevation Resident's interpretation: Reperfusion pattern/Wellens' with biphasic T waves in V2 and V3, and in comparison to an EKG in 2020 this is new. Total coronary occlusion, if very brief, may have minimal infarction and yet be very dangerous. Am Heart J. 2000;139:430–436.

Coronary 117

Coronary STEMI ED OR 117

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

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. A reliable study would keep track of all patients with shockable arrest and analyze the ones who were not enrolled to see their outcomes. This study failed to do so. 5% vs. 58%!!

Defibrillator 93

Defibrillator STEMI Coronary ALS 93

EMS 12-Lead

AUGUST 14, 2022

A second 12 Lead ECG was recorded: This is a testament to the dynamic nature of coronary thrombosis and thrombolysis. Here the ST segments are not so deep, nor are the T waves so wide and bulky, because of improved coronary flow at the level of the occlusion. But the lesion is still active!

STEMI 130

STEMI MICU CAD Coronary 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-9-1-1 121

E-9-1-1 Coronary ACS BLS 121

Dr. Smith's ECG Blog

OCTOBER 15, 2024

Additionally, his cardiac telemetry monitor showed runs of accelerated idioventricular rhythm, a benign arrhythmia often associated with coronary reperfusion. The patient is a 75-year old man with known coronary disease, including prior LAD and LCx OMI. That this patient has severe underlying coronary disease is indisputable.

OR 109

OR STEMI Coronary ED 109

Dr. Smith's ECG Blog

DECEMBER 11, 2023

For the same reason, you should not delay coronary angiography because pain resolves with morphine. A few hours later, the patient underwent coronary angiography, which showed complete occlusion of her mid left circumflex artery. But pain is a critical signal for urgency in the context of acute coronary syndrome. Mukherjee, D.,

E-9-1-1 122

E-9-1-1 ACS Coronary STEMI 122

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 76

STEMI Paramedic Coronary EMS 76

Dr. Smith's ECG Blog

MAY 3, 2024

See the variety of Left Main Occlusion ECGs here: How does Acute Total Left Main Coronary occlusion present on the ECG? == MY Comment , by K EN G RAUER, MD ( 5/3 /2024 ): == Most patients with acute LMain Occlusion do not survive to make it to the hospital. Left Main Non-Occlusive ACS presents with widespread ST Depression and STE in aVR.

ACS 117

ACS ED Coronary EMS 117

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

AUGUST 6, 2024

All coronary arteries were patent without atherosclerotic change. Dr. Myocarditis can be very difficult to separate from OMI on ECG, and often some form of coronary artery imaging will need to be done to rule out OMI. The ECG shows slight ST Elevation in an inferolateral distribution. Notice how QOH is not fooled by this ST-Elevation.

Coronary 88

Coronary OR STEMI EMS 88

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 finding of dynamic ST-T wave changes on serial tracings in association with a change in chest pain symptoms ( SEE My Comment in the July 21, 2020 post ).

STEMI 52

STEMI Coronary EMR ALS 52

Dr. Smith's ECG Blog

JANUARY 8, 2024

She went to angio and had normal coronaries. No d-dimer or CT pulmonary angiogram was done when they discovered that she had normal coronary arteries. Think of this diagnosis when a patient with CP and SOB + elevated troponin — has normal coronary arteries on cardiac cath. I discussed all results with patient.

Coronary 71

Coronary STEMI EMS OR 71

Dr. Smith's ECG Blog

JANUARY 9, 2023

Repeat CT angio chest (not CT coronary, unclear what protocol) showed possible LAD aneurysm and thrombus. Finally, coronary angiography was performed (at least 5 days after presentation) which confirmed LAD aneurysm with large thrombus burden, TIMI 0 flow, thrombectomy performed.

Coronary 52

Coronary STEMI Heart Attack OR 52

Dr. Smith's ECG Blog

DECEMBER 13, 2023

Knowing the patient has a history of coronary disease could be relevant to today's case — as it should add to our suspicion of a new acute event. If this is the case — this size of a Qr wave in lead III, as well as the seemingly wide Q in lead aVF — would seem to suggest prior inferior infarction a t some point in the past.

EMR 116

EMR Coronary OR STEMI 116

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

MAY 19, 2020

Angiography showed normal coronaries. MINOCA: Myocardial Infarction in the Absence of Obstructive Coronary Artery Disease). Here is my comment on MINOCA: "Non-obstructive coronary disease" does not necessarily imply "no plaque rupture with thrombus." 2) overlooked obstructive coronary disease (e.g., The K was normal.

Defibrillator 52

Defibrillator CPR Coronary CAD 52

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 November 10, 2020 post — for PTA. The October 17, 2020 post — for a 70-year old woman with " Artifactual VT ". Written by Willy Frick A 57 year old man with was admitted to the hospital with chest pain.

Defibrillator 79

Defibrillator ALS Coronary OR 79

Dr. Smith's ECG Blog

MAY 13, 2020

On echo, OMI has a wall motion abnormality, but SI usually does not. == MY Comment by K EN G RAUER, MD ( 5/13/2020 ): == It’s good to periodically review the differential diagnosis of the diffuse subendocardial ischemia. The artery is open, but flow is insufficient to perfuse the entire myocardial thickness (subendocardial AND subepicardial).

Coronary 52

Coronary ACS EMS STEMI 52

REBEL EM

MARCH 30, 2023

Clinical Question : In patients who suffer an OHCA without ST-segment elevation on the post-resuscitation ECG, will early coronary angiogram (CAG) vs. delayed CAG improve outcomes? Emergency vs Delayed Coronary Angiogram in Survivors of Out-of-Hospital Cardiac Arrest: Results of the Randomized, Multicentric EMERGE Trial. Janssens, G.

Coronary 83

Coronary CPR OR ICU 83

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. Of the Non-STEMI in our cohort, about 25% will actually have acute coronary occlusion. So this study is worthless and must be ignored.

STEMI 92

STEMI Coronary Paramedic OR 92

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-9-1-1 110

E-9-1-1 Coronary EMS ED 110

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-9-1-1 120

E-9-1-1 OR Coronary ACS 120

ACEP Now

JULY 7, 2023

Extracorporeal membrane oxygenation Of patients with out-of-hospital cardiac arrest presenting to the ED in refractory VF, a majority have significant coronary artery disease, much of which is amenable to percutaneous coronary intervention. Circulation. 2019;139(12):e530-e552. Yannopoulos D, et al. J Am Coll Cardiol.

Defibrillator 98

Defibrillator OR ALS Epinephrine 98

EMDocs

SEPTEMBER 7, 2024

A 70-year-old female with a past medical history of hypertension, coronary artery disease s/p 2x drug eluting stent placement one month ago, atrial fibrillation on apixaban presents to the ED with weakness and lightheadedness. 2020 May;13(5):545-555. Epub 2020 Mar 3. 2020 Jun;13(6):i. F, RR 16, SpO2 97% on room air.

EMS 75

EMS E-9-1-1 Operating Room OR 75

Dr. Smith's ECG Blog

MAY 24, 2022

No angiographically significant obstructive coronary artery disease. CT coronary angiogram is excellent , but is rarely available outside of business hours, and hardly ever at night. The Cath lab was activated. Here is the report: Cath lab activation at 3 am by the ED for atypical CP, and elevated troponin with diffuse STT changes.

Coronary 52

Coronary OR ED 52

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 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

SEPTEMBER 16, 2024

A coronary angiogram was done that did not show significant coronary artery disease. I have periodically called attention to examples of the Ashman phenomenon as they occur in Dr. Smith's ECG Blog ( See My Comments in the January 5, 2020 post — the June 17, 2020 post — and the March 30, 2023 post , among others ).

Defibrillator 67

Defibrillator Coronary OR ALS 67

Dr. Smith's ECG Blog

JULY 24, 2024

And regarding arrhythmias: For more on the regular WCT — See My Comment in the May 5, 2020 post and in the April 15, 2020 post in Dr. Smith's ECG Blog. Many ( if not most ) NSTEMIs are actually OMIs ( = acute coronary O cclusion MI s ). Smith's ECG Blog. 7:42 — Error #3: The ECG criteria for diagnosing an OMI?

E-9-1-1 52

E-9-1-1 Coronary STEMI OR 52

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 28, 2022

Electrocardiographic diagnosis of acute coronary Occlusion Myocardial Infarction in ventricular paced rhythm using the modified Sgarbossa criteria. There is no doubt about these 2 EKGs: they are due to acute coronary occlusion. Annals of Emergency Medicine 2021. Diagnosis: Obvious Inferior and lateral Occlusion MI.

Coronary 52

Coronary Paramedic EMS ICU 52

Dr. Smith's ECG Blog

JULY 27, 2023

I was not worried for a coronary etiology. Possible explanations include: i ) Coronary vasospasm, with a brief period of coronary occlusion; ii ) Supply-demand mismatch ( Type II MI ) — precipitated by amphetamine-induced catecholamine surge; and / or , iii ) Catecholamine-mediated platelet aggregation with subsequent thrombus formation.

Coronary 52

Coronary ACS Naloxone Plasma 52

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

JUNE 11, 2024

To add to this complexity ( as per My Comment in the August 22, 2020 post in Dr. Smith's ECG Blog ) — the ST-T wave appearance in repolarization variants may be dynamic ! It is clearly missed by the conventional algorithm.

STEMI 112

STEMI Coronary Emergency Department OR 112