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. Published 2022 Feb 20.

ACS 87

ACS Coronary ALS CAD 87

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

Angiogram No obstructive epicardial coronary artery disease Cannot exclude non-ACS causes of troponin elevation including coronary vasospasm, stress cardiomyopathy, microvascular disease, etc. Lindahl et al. From Gue at al. Most studies examine undifferentiated ACS cohorts, with only a handful providing separate data.

Coronary 104

Coronary E-9-1-1 STEMI ACS 104

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). History sounds concerning for ACS (could be critical stenosis, triple vessel), but differential also includes dissection, GI bleed, etc. Knotts et al.

Coronary 52

Coronary ACS STEMI ALS 52

ALiEM

FEBRUARY 9, 2024

The 2022 American College of Cardiology (ACC) pathway provides timely guidance [1]. Applying the 2022 ACC guideline Before delving into the specifics of the hs-cTn pathways, start with the ECG. The ACC 2022 pathway has a section dedicated to ECGs in ischemia [1], and FOAMcast has a great visual summary. J Am Coll Cardiol.

E-9-1-1 276

E-9-1-1 ED Coronary ALS 276

Dr. Smith's ECG Blog

APRIL 18, 2024

Non-STEMI guidelines call for “urgent/immediate invasive strategy is indicated in patients with NSTE-ACS who have refractory angina or hemodynamic or electrical instability,” regardless of ECG findings.[1] Amsterdam et al. Alencar et al. Lupu et al. Clin Cardiol 2022 4. Herman, Meyers, Smith et al.

STEMI 121

STEMI Coronary ALS CAD 121

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

ACEP Now

MARCH 14, 2024

Current can be alternating current (AC) or direct current (DC) with AC typically more dangerous as it is more likely to cause tetanic contractions and increase contact time with the electrical source. 2,3,5 Except for laundry or electrical car outlets (240 V AC), all U.S. household outlets are rated at 120 V AC.

Operating Room 52

Operating Room ACS Critical Care Coronary 52

Dr. Smith's ECG Blog

JUNE 8, 2023

As recurrent ischaemia is the principle event reduced by early intervention in NSTE-ACS, these are important endpoint events occurring with delayed angiography and there is a consistent signal for harm now from two data sources.”[5] Kontos et al. J Am Coll Cardiol 2022 Nov 15;80(20):1925-1960 2. Welsh et al. Busk et al.

STEMI 63

STEMI Coronary Paramedic ALS 63

Pediatric EM Morsels

AUGUST 18, 2023

Morley 2022) This myth is: BUSTED. References: Ross RK, Kinlaw AC, Herzog MM, Funk MJ, Gerber JS. PMID: 27940800 Hersch AL, Gerber JS, Hicks LA, Pavia AT. Symptoms resolved within 24 hours of withdrawal of the medication. However, Fluroquinolone resistance is increasing, so they should only be used if absolutely necessary!

E-9-1-1 130

E-9-1-1 OR ACS ALS 130

EMDocs

OCTOBER 21, 2023

The NIHSS cutoff that predicts outcomes is 4 points higher in AC compared with PC infarctions. References: Gaillard F, Glick Y, Tatco V, et al. Updated 2022 Dec 22]. Updated 2022 Oct 15]. 61.4.496 Navi BB, Kamel H, Shah MP, et al. Goldmakher GV, Camargo EC, Furie KL, Singhal AB, Roccatagliata L, Halpern EF, et al.

EMS 74

EMS ALS OR ACS 74

ACEP Now

MAY 9, 2024

Taking a different approach than the authors of the AHRQ report, Auerbach et al used a “look back” approach to perform both qualitative and quantitative evaluations of the types and frequencies of errors occurring in hospital settings. References Newman-Toker DE, Peterson SM, Badihian S, et al. Auerbach AD, Lee TM, Hubbard CC, et al.

Emergency Department 52

Emergency Department ICU ALS ACS 52

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

Studies such as those by Moise et al 14 and Ellis et al 39 have shown that the relative risk of developing an acute myocardial infarction in the territory supplied by an artery with a 70%. years, with the interval as long as 12 or 18 years in some studies. Nor was there a challenge to look for coronary spasm.

Coronary 80

Coronary ACS OR EMR 80

Dr. Smith's ECG Blog

APRIL 17, 2023

He had no symptoms of ACS. His HEAR score (before troponin resulted) was documented at 3, with documentation stating "low suspicion for ACS." A troponin this high in a patient with no known chronic troponin elevation, and active acute ACS symptoms, has a very high likelihood of type 1 ACS regardless of the ECG.

OR 52

OR STEMI ACS Emergency Department 52

ACEP Now

FEBRUARY 11, 2024

Sodhi M, Rezaeianzadeh R, Kezouh A, et al. Ahmann AJ, Capehorn M, Charpentier G, et al. ACS chemical neuroscience molecule spotlight on Contrave. ACS Chem Neurosci. Bansal AB, Al Khalili Y. Updated December 11, 2022. A prescription for achieving equitable access to antiobesity medications. JAMA Health Forum.

Overdose 52

Overdose ACS Plasma ALS 52

Dr. Smith's ECG Blog

MAY 31, 2023

And now this finding is even formally endorsed as a "STEMI equivalent" in the 2022 ACC guidelines!!! 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. de Winter et al in N Engl J Med 359:2071-2073, 2008.

STEMI 80

STEMI Coronary ACS OR 80

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. Comment by K EN G RAUER, MD ( 12/12 /2022 ): = I will summarize in 4 words the important message conveyed by Dr. Meyers in today's post = "Be Aware of Pseudo-Normalization!"

OR 52

OR ACS STEMI Coronary 52

Don't Forget the Bubbles

SEPTEMBER 18, 2023

2022 Dec;41(12):947–52. Davidson L, Foley DA, Clifford P, Blyth CC, Bowen AC, Hazelton B, et al. 2022 Jun;58(6):1007–12. Frost HM, Bizune D, Gerber JS, Hersh AL, Hicks LA, Tsay SV. 2022 Dec;251:98-104.e5. NICE; [cited 2022 Dec 28]. 2017 Sep 7 [cited 2022 Dec 28];2022(8).

Emergency Department 142

Emergency Department E-9-1-1 ALS OR 142

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

MAY 8, 2023

This was several months after the 2022 ACC Guidelines adding modified Sgarbossa criteria as a STEMI equivalent in ventricular paced rhythm). The ACC likely made this new recommendation for the MSC in ventricular paced rhythm in large part due to the "PERFECT" Study (Meyers is an author, and Smith was the senior author): Dodd et al.

STEMI 52

STEMI Coronary ED ACS 52

Dr. Smith's ECG Blog

DECEMBER 6, 2022

S yncope is an uncommon presentation of ACS, but anginal equivalents are more likely in older patients with diabetes 2. The highest risk group are patients with a cardiac cause of their syncope, in whom 1-year mortality can reach 33% ( Koene et al: J Arrhythm 33(6):533-544, 2017 ). Take home 1.

STEMI 52

STEMI ACS Coronary OR 52

Don't Forget the Bubbles

JULY 22, 2024

Compare this with the Panickar et al. Fortunately, Lee et al. Lee B, Turner S, Borland M, Csonka P, Grigg J, Guilbert TW, et al. Future of Pre-School Wheeze Whilst Lee et al. Cronin JJ, McCoy S, Kennedy U, An Fhailí SN, Wakai A, Hayden J, et al. study from 200 9. The Lancet Respiratory Medicine [Internet].

E-9-1-1 105

E-9-1-1 ALS ACS ED 105

EMDocs

FEBRUARY 12, 2024

References/Further Reading (1) Byrne AL, Bennett M, Chatterji R, Symons R, Pace NL, Thomas PS. 11) Webb RK, Ralston AC, Runciman WB. 2022 Nov;10(11):1086-1098. Epub 2022 Aug 29. Updated 2022 Sep 12]. Peripheral venous and arterial blood gas analysis in adults: are they comparable? PMID: 11685301. (10) 10) Jubran A.

Emergency Department 94

Emergency Department E-9-1-1 ED ICU 94

Dr. Smith's ECG Blog

JANUARY 3, 2022

It encompasses the complete range of ACS, including OMI, NOMI, and coronary thromboses that have the potential to rapidly propagate and become OMI and therefore has no specificity. References 1. -- Hillinger P, Strebel I, Abacherli R, et al. Int J Cardiol 2019 2. -- Meyers HP, Bracey, Smith et al. J of Emerg Med 2021.

STEMI 52

STEMI Coronary ALS ACS 52

Don't Forget the Bubbles

SEPTEMBER 13, 2023

An expert committee appraised the evidence behind recommendations to avoid imaging to inform the 2022 NICE guidance. doi:10.1093/tropej/fmz071 Expert Panel on Pediatric Imaging, Trofimova A, Milla SS, et al. 2019-0134 Hirtz D, Ashwal S, Berg A, et al. Published 2022 Jan 13. J Trop Pediatr. 2020;66(3):299-314. Pediatr Rev.

E-9-1-1 131

E-9-1-1 Emergency Department ALS OR 131

Dr. Smith's ECG Blog

DECEMBER 27, 2023

The original term " benign early repolarization" has fallen out of favor since the seminal paper by Haïssaguerre et al. As a result, even before looking at this patient's initial ECG — he falls into a high -prevalence likelihood group for ACS ( for an A cute C oronary S yndrome ). per 100,000 to 11 per 100,000 [Rosso]. link] Lupu, L.,

E-9-1-1 120

E-9-1-1 OR Coronary ACS 120

The Skeptics' Guide to EM

MAY 28, 2022

Date: May 24th, 2022 Reference: Broder et al. Date: May 24th, 2022 Reference: Broder et al. Reference: Broder et al. AEM May 2022 This is an SGEMHOP episode which means we have the lead author on the show. In the context of recurrent chest pain, they made eight key recommendations.

Emergency Department 100

Emergency Department ALS ACS Coronary 100

ACEP Now

AUGUST 12, 2024

Considering hyperacute T-waves have been accepted as STEMI equivalents, it is possible that pseudonormalization could gain more recognition as an indicator of ACS. 2022 Nov, 80 (20) 1925–1960. 5 Studies looking at this phenomenon in the emergency department setting for patients presenting with chest pain are lacking. J Am Coll Cardiol.

Emergency Department 52

Emergency Department STEMI ACS ED 52

Dr. Smith's ECG Blog

MARCH 4, 2023

MOREVER, the morphology of the TWI is just not right for ACS. S1Q3T3 This is a paper worth reading : Marchik et al. Kosuge et al. 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. inverted T-waves in V1 and V2, 1.8;

ACS 52

ACS ALS OR 52

EMDocs

JANUARY 6, 2024

10 Although this is not the same pathophysiology seen in ACS from an acute plaque rupture leading to coronary artery occlusion, patients can have relatively abrupt coronary ischemia causing ACS due to acute, concentric vessel narrowing. 2018.07.022 Pothuru S, Chan WC, Goyal A, et al. J Heart Lung Transplant.

EMS 63

EMS E-9-1-1 ACS Coronary 63

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. Reference on Troponins: Xenogiannis I, Vemmou E, Nikolakopoulos I, et al. Lindahl et al. From Gue at al.

Emergency Department 52

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

EMDocs

AUGUST 31, 2023

Accessed May 7, 2022. Accessed May 7, 2022. link] Li Z, Krippendorff BF, Sharma S, Walz AC, Lavé T, Shah DK. Accessed May 7, 2022. Accessed May 7, 2022. Bush SP, Ruha AM, Seifert SA, et al. StatPearls Publishing; 2022. Accessed May 17, 2022. link] Kanaan NC, Ray J, Stewart M, et al.

Allergic Reaction 72

Allergic Reaction Plasma ALS EMS 72

REBEL EM

FEBRUARY 2, 2023

Paper: Mason JM, et al. These results were corroborated with other another study by Gritensko et al. Sepsis, hyperthyroidism, dehydration, heart failure, ACS, etc). References Mason JM, et al. 2022 Sep 7. 2018, PMID: 30571262 Gritsenko, Diana, et al. Link to Paper Here Shojaee M, et al. 2, 2018, pp.

Emergency Department 52

Emergency Department ALS Critical Care ED 52

Dr. Smith's ECG Blog

JANUARY 6, 2023

Lupu L, et al. Clin Cardiol 2022; [link] Labs included: hsTnI 156 ng/L, Hb 12 g/dL, WBC 12x10^9/L, Cr. 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. mg/dL, K 3.5

ACS 52

ACS Coronary ICU STEMI 52

Don't Forget the Bubbles

JUNE 30, 2023

2022 Dec;57(12):986-993. Joint statement from the American College of Surgeons Committee on Trauma (ACS COT) and the American College of Emergency Physicians (ACEP) regarding the clinical use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). Trials 23, 384 (2022). Laan DV, Vu TD, Thiels CA et al.

E-9-1-1 139

E-9-1-1 FFP Plasma Emergency Department 139

Dr. Smith's ECG Blog

JANUARY 17, 2023

In the December 5, 2022 post of Dr. Smith's ECG Blog — We show 4 additional cases of this pulse-tap artifact. Finally, as I discuss in My Comment in the August 26, 2022 post ( which applies the electrophysiologic principles of Rowlands & Moore: J. This is no longer the case! Why are the smallest artifactual deflections GREEN ?

ALS 52

ALS ACS OR ED 52

REBEL EM

JULY 14, 2022

Paper: Nassal MMJ, et al. 2022 Mar; 17. REFERENCES: Nassal MMJ, et al. 2022 Mar; 17. PMID: 34968531 Rittenberger JC, et al. PMID: 21756969 Coppler PJ, et al. PMID: 25636896 Schober A, et al. PMID: 27368428 Elmer J, et al. PMID: 30060961 Koller AC, et al. Resuscitation.

ICU 52

ICU ALS OR CPR 52

Dr. Smith's ECG Blog

OCTOBER 13, 2022

The emergency physician wasn’t sure what to make of the changes from one ECG to the next but was concerned about ACS. Rosner et al. Int J Cardiol 2014. == MY Comment by K EN G RAUER, MD ( 10/13/2022 ): == I suspect most cases of acute OMI that occur in association with WPW — are overlooked! What do you think? Goldberger.

STEMI 52

STEMI Coronary OR ACS 52