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. Clin Cardiol 2022 4. But does this matter?

STEMI 121

STEMI Coronary ALS CAD 121

The Skeptics' Guide to EM

MAY 28, 2022

Date: May 24th, 2022 Reference: Broder et al. Date: May 24th, 2022 Reference: Broder et al. AEM May 2022 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called First10EM.com Case: A 33-year-old male presents to the emergency department (ED) complaining of abdominal pain.

Emergency Department 100

Emergency Department ACS ALS Coronary 100

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 119

Coronary ACS ED OR 119

Dr. Smith's ECG Blog

MAY 10, 2023

A CT Coronary angiogram was ordered. Here are the results: --Minimally obstructive coronary artery disease. --LAD Although a lesion is not visible anatomically on this CT scan, coronary catheter angiography could be considered based on Cardiology evaluation." A repeat troponin returned at 0.45 CAD-RADS category 1. --No

Coronary 52

Coronary STEMI CAD OR 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. They are simply Hyperacute T-waves with depressed ST takeoff.

STEMI 96

STEMI Coronary ACS OR 96

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 83

ACS Coronary ALS CAD 83

Dr. Smith's ECG Blog

JUNE 15, 2023

Thus, this does NOT meet STEMI criteria (though, as of 2022, it is a formal "STEMI equivalent", assuming everyone agrees that this is de Winter morphology, for which there is currently no objective definition). Also, if you use the LAD OMI formula : QT = 420, RAV4 = 5 mm, QRSV2 = 6 mm, STE60V3 = 2.5 mm, the value is 22.2 (LAD

STEMI 98

STEMI Coronary ACS OR 98

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 98

STEMI ACS OR ALS 98

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. Anything more on history?

Coronary 52

Coronary ACS STEMI ALS 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

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-9-1-1 116

E-9-1-1 Coronary EMS ED 116

Dr. Smith's ECG Blog

SEPTEMBER 9, 2024

The patient was thought to have low likelihood of ACS, and cardiology recommended repeat troponin, urine drug testing, and echocardiogram. At that point, cardiology elected to treat for ACS. Another option would be to use Optical Coherence Tomography for Coronary Imaging ). Initial hscTnI was 10 ng/L (ref. <14).

OR 66

OR Coronary ACS EMS 66

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

EMDocs

OCTOBER 21, 2023

A 68-year-old male with a past medical history of hypertension, diabetes mellitus, and coronary artery disease with a drug eluting stent placed 2 months ago presents with dizziness and vomiting that began 3 hours ago. The NIHSS cutoff that predicts outcomes is 4 points higher in AC compared with PC infarctions. Updated 2022 Dec 22].

EMS 98

EMS ALS OR ACS 98

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

OCTOBER 10, 2022

If this is ACS with Aslanger's pattern , the ST depression vector of subendocardial ischemia (due to simultaneous 3 vessel or left main ACS) is directed toward lead II (inferior and lateral). Thus, this apparently is Aslanger's Pattern (inferior OMI with single lead STE in lead III, with simultaneous subendocardial ischemia).

ACS 52

ACS CPR CAD Heart Attack 52

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. Sequence of events in angina at rest: Primary reduction in coronary flow. 2022 Nov, 80 (20) 1925–1960. Normalization of abnormal T waves in ischemia. Arch Intern Med.

Emergency Department 52

Emergency Department STEMI ACS ED 52

Dr. Smith's ECG Blog

JANUARY 6, 2023

Immediate and early percutaneous coronary intervention in very high-risk and high-risk Non-STEMI patients. 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. Lupu L, et al. mg/dL, K 3.5

ACS 52

ACS Coronary ICU STEMI 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

NOVEMBER 23, 2022

ST depression maximal in V1-V4, in the context of ACS symptoms and unexplained by QRS abnormality or tachydysrhythmia, should be considered posterior OMI until proven otherwise. Today's patient is high-risk ( ie, in a high "prevalence" group for having an acute coronary event ). This apparently was not done in today's case.

Coronary 52

Coronary Heart Attack ED CPR 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). Electrocardiographic Diagnosis of Acute Coronary Occlusion Myocardial Infarction in Ventricular Paced Rhythm Using the Modified Sgarbossa Criteria. Modified Sgarbossa Criteria Refresher!

STEMI 52

STEMI Coronary ED ACS 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. This is in contrast to sinus rhythm with a heart rate below 100. == MY Comment, by K EN G RAUER, MD ( 8/17 /2022 ): == I was shown today's ECG without the benefit of any history. The April 17, 2022 post ( Leads V1,V2 misplacement ).

Coronary 52

Coronary ACS OR 52

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

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

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

JANUARY 23, 2023

Recall that, in the setting of ACS symptoms, ST depression that are maximal in leads V1-V4 (as opposed to V5 and V6) not attributable to an abnormal QRS complex is specific for OMI. Optimal treatment for today's patient would have been prompt cath with PCI to the "culprit" artery with the goal of maintaining coronary perfusion.

ACS 52

ACS Coronary Defibrillator STEMI 52

Dr. Smith's ECG Blog

DECEMBER 18, 2022

cm distal to the non-coronary cusp of the aortic valve." The operative report and radiology reads do not comment specifically as to whether the dissection flap was partially or fully obstructing coronary flow, or whether it was obstructing the left main or the RCA. Intraoperative TEE noted "Type A aortic dissection arising 1.0

Coronary 40

Coronary ACS EMS ED 40

Dr. Smith's ECG Blog

FEBRUARY 6, 2023

Corroborating this is the subtle ST depression in V2-V3 which is inappropriate for the normal QRS complex, and in the context of ACS, we have shown this is quite specific for posterior OMI. In the context of ACS, ST depression maximal in V1-V4 (rather than V5-V6) not due to a QRS abnormality is specific for posterior OMI.

ACS 52

ACS EMS STEMI Coronary 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. 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! Here’s the third ECG, 30 minutes after the second.

STEMI 52

STEMI Coronary OR 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. On discharge the inferior deWinter waves resolved and the lateral T waves deflated and inverted. Take home 1. C ircumflex occlusions can have subtle to no ECG changes 3. Y ou can’t trust ECG's labeled "normal" 4.

STEMI 52

STEMI ACS Coronary OR 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-9-1-1 102

E-9-1-1 EMS Coronary ACS 102

EMDocs

JANUARY 6, 2024

3,10 Coronary Allograft Vasculopathy Nicknamed “The Achilles Heel of Heart Transplantation,” this accounts for the majority of patient mortality in the 5-10 year range. 10 It affects the whole length of the vessel and all layers of the coronary vasculature rather than just the intima, which is seen in non-transplant atherosclerosis.

EMS 91

EMS E-9-1-1 ACS Coronary 91

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. STEMI criteria, and automated interpretations based on it, will miss acute coronary occlusion. Take home 1. Welsh et al.

STEMI 86

STEMI Coronary Paramedic ALS 86

Dr. Smith's ECG Blog

DECEMBER 5, 2023

Acute coronary syndrome in a pediatric patient? A final ECG was perfomed on hospital day 2: Persistent ST elevation in the inferior leads with slight reciprocal ST depression in aVL Teaching points - It is essential to consider ACS in all age groups. Ultimately, cardiac cath was done — revealing patent coronary arteries.

Coronary 121

Coronary CAD ACS ALS 121

EMDocs

NOVEMBER 4, 2024

54 It is vital to consider dangerous epigastric pain mimickers like acute coronary syndrome (ACS), hepatobiliary disease, or pancreatitis. Comparison of factors associated with atypical symptoms in younger and older patients with acute coronary syndromes. 2022 May;33(2):307-333. Feb 1976;131(2):219-23. J Korean Med Sci.

E-9-1-1 105

E-9-1-1 ED Emergency Department ALS 105

Dr. Smith's ECG Blog

MARCH 14, 2025

He has a history of coronary artery disease and a STEMI two years prior that was treated with primary PCI. These findings were not recognized, and because the patient (after morphine) reported improved symptoms, urgent coronary angiography was not performed. He was given ASA and sublingual NTG and taken to the ED.

ACS 106

ACS STEMI Coronary OR 106

Core EM

NOVEMBER 30, 2024

Acute coronary syndrome (ACS), cardiomyopathy, cardiogenic shock, aortic dissection, pulmonary embolism, myocarditis/pericarditis, cardiac tamponade, coronary artery dissection, coronary vasospasm, ventricular aneurysm What are your next steps in management for this patient?

Coronary 130

Coronary STEMI MICU ACS 130