Dr. Smith's ECG Blog

APRIL 22, 2024

A comparison of electrocardiographic changes during reperfusion of acute myocardial infarction by thrombolysis or percutaneous transluminal coronary angioplasty. Lemkes JS, et al. Total coronary occlusion, if very brief, may have minimal infarction and yet be very dangerous. Am Heart J. 2000;139:430–436. Eur Heart J [Internet].

Coronary 121

Coronary STEMI ED OR 121

Dr. Smith's ECG Blog

SEPTEMBER 11, 2024

Acute MI per se usually does not depress cardiac function and blood pressure enough to cause syncope ( Mostafa et al — J Com Hosp Intern Med Perspect 13(4):9-12, 2023 - ). Other cardiac-related causes for syncope associated with acute MI may include malignant ventricular arrhythmias and bradyarrhythmias including AV block.

EMS 108

EMS CPR ED Coronary 108

EMDocs

JULY 1, 2023

Upon further research in the 1970’s, retrospective data from autopsies of those patients showed coronary aneurysms 5 Pathophysiology: Kawasaki Disease is a vasculitis of medium sized arteries. Tomisaku Kawasaki, who noticed 50+ similar pediatric presentations between the years 1961 and 1967. Lakhani, N. BMC Pediatrics. 2018;18(334).

EMS 66

EMS Coronary ED OR 66

ALiEM

FEBRUARY 9, 2024

The 2022 American College of Cardiology (ACC) pathway provides timely guidance [1]. Intermediate-risk patients may be further stratified based on recent stress testing or coronary angiogram findings plus a modified HEART or Emergency Department Assessment of Chest Pain (EDACS) score. Time to know your hs-cTn better.

E-9-1-1 276

E-9-1-1 ED Coronary ALS 276

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. Kontos et al.

STEMI 63

STEMI Coronary Paramedic ALS 63

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. Furthermore, pertinent electrolyte values (e.g. potassium) were within normal parameter.

E-9-1-1 130

E-9-1-1 Coronary ALS ICU 130

EMDocs

FEBRUARY 7, 2024

American Gastroenterological Association issued a practice guideline in November 2022 recommending that semaglutide 2.4 GLP-1 agonists are also associated with improved ejection fraction, coronary blood flow, and cardiac output while reducing the risk of cardiovascular events, infarction size, and all-cause mortality. How do they work?

Allergic Reaction 75

Allergic Reaction ALS CAD OR 75

REBEL EM

SEPTEMBER 12, 2022

Background: Coronary artery disease can result in hibernating myocardium (chronic myocardial contractile dysfunction) due to ischemia. The theory is that there is reduced coronary blood flow and increased myocardial demand resulting in impaired contractility. Paper: Perera D et al. OMT: 38.0% HR 0.99; 95% CI 0.78 to 1.27; p = 0.96

Coronary 52

Coronary ALS OR EMS 52

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 117

Defibrillator Coronary ALS STEMI 117

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

Hgb 11g/dL (110g/L) and leukocytosis, and a mildly elevated troponin (36 ng/L, with normal 1mm STE in aVR due to ACS will require coronary artery bypass surgery for revascularization, the infarct artery is often not the LM, but rather the LAD or severe 3-vessel disease. Harhash AA, Huang JJ, Reddy S, et al. Knotts et al.

Coronary 52

Coronary ACS STEMI ALS 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. Unfortunately, vascular remodeling is variable and inconsistent.

Coronary 80

Coronary ACS OR EMR 80

Dr. Smith's ECG Blog

MAY 23, 2023

2022 Jan;51:384-387. 2022 May;55:180-182. 2022 May;55:180-182. Epub 2022 Mar 17. 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. Am J Emerg Med. doi: 10.1016/j.ajem.2021.11.023.

STEMI 89

STEMI Coronary Paramedic OR 89

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 October 21, 2022 post — for " artifactual VT". Additional review of ECG artifacts by Pérez-Riera et al ( Ann Noninvasic Electrocardiol 23:e12494, 2018 ) VT Artifact — by Knight et al: NEJM 341:1270-1274, 1999.

Defibrillator 79

Defibrillator ALS Coronary OR 79

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

The De Winter ECG pattern: morphology and accuracy for diagnosing acute coronary occlusion: systematic review. Hayakawa A, Tsukahara K, Miyagawa S, et al. Published 2022 Feb 20. Immediate and early percutaneous coronary intervention in very high-risk and high-risk non-ST segment elevation myocardial infarction patients.

ACS 87

ACS Coronary ALS CAD 87

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. References: Gaillard F, Glick Y, Tatco V, et al. Updated 2022 Dec 22]. Updated 2022 Oct 15]. Arch Neurol.

EMS 74

EMS ALS OR ACS 74

Dr. Smith's ECG Blog

OCTOBER 18, 2023

Dr. Smith’s ECG Blog has published a growing list of over 40 cases of ECGs falsely labeled ‘normal’ by the computer which are diagnostic of Occlusion MI, and Smith et al. Smith’s ECG Blog has published a growing list of over 40 cases of ECGs falsely labeled ‘normal’ by the computer which are diagnostic of Occlusion MI, and Smith et al.

STEMI 122

STEMI Emergency Department Coronary OR 122

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

SEPTEMBER 5, 2024

A Short Comment on PIRP and T Waves: Oliva et al found a strong association of myocardial rupture with postinfarction regional pericarditis. Another possible cause of pseudonormalization of T waves mentioned many times on this blog is the pseudonormalization caused by re-occlusion of an infarct related reperfused coronary artery.

STEMI 106

STEMI Coronary OR ALS 106

Dr. Smith's ECG Blog

DECEMBER 29, 2023

STEMI criteria is bad at differentiating between normal variant and acute coronary occlusion or reperfusion, and initial troponin levels don't differentiate between occlusive and non-occlusive MI 3. the presence of J waves from early repolarization doesn’t rule out an acute coronary occlusion 4. McLaren et al, including Meyers/Smith.

STEMI 74

STEMI Coronary OR ALS 74

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

MAY 31, 2023

And now this finding is even formally endorsed as a "STEMI equivalent" in the 2022 ACC guidelines!!! Association of intravenous morphine use and outcomes in acute coronary syndromes: Results from the CRUSADE Quality Improvement Initiative. de Winter et al in N Engl J Med 359:2071-2073, 2008. Am Heart J. 2005;149:1043–1049.

STEMI 80

STEMI Coronary ACS OR 80

ACEP Now

MARCH 14, 2024

Tintinalli JE, Stapczynski J, Ma O, et al. Acute myocardial infarction with normal and near normal coronary arteries. Documentation with coronary arteriography within 12 1/2 hours of the onset of symptoms in two cases (three episodes). Arnoldo BD, Purdue GF, Kowalske K, et al. 2023 Jul 17. In: StatPearls [Internet].

Operating Room 52

Operating Room ACS Critical Care Coronary 52

REBEL EM

SEPTEMBER 5, 2022

Paper 1: Schmidt HJ et al. PMID: 360027567 [ Access on Read by QxMD ] Paper 2: Kjaergaard J et al. References: Schmidt HJ et al. PMID: 360027567 [ Access on Read by QxMD ] Kjaergaard J et al. A higher MAP may offer advantages due to improved cerebral perfusion pressure, however data is lacking. Liberal O2: 33.9%

ICU 52

ICU ALS OR CPR 52

Dr. Smith's ECG Blog

AUGUST 19, 2023

Herzog et al. Khan et al. Problem #1: As I emphasized in My Comment in the December 6, 2022 post — Not all patients with acute MI report chest pain. As we've often emphasized in Dr. Smith's ECG Blog — Posterior leads often provide false reassurance ( See My Comment at the bottom of the page in the September 21, 2022 post ).

STEMI 86

STEMI ACS OR ALS 86

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. J of Emerg Med 2021.

STEMI 52

STEMI Coronary ALS ACS 52

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). Aspirin 81 mg daily.

STEMI 52

STEMI Coronary ACS ED 52

Dr. Smith's ECG Blog

SEPTEMBER 21, 2022

This is most consistent with ischemia/infarction in the distribution of the left circumflex coronary artery. Meyers, Bracey, Smith, et al. The February 10, 2022 post in Dr. Smith's ECG Blog — My Comment ( at the bottom of the page ) illustrates the Mirror Test in a case with posterior reperfusion waves ( ie, tall anterior T waves ).

STEMI 52

STEMI ED Coronary OR 52

Dr. Smith's ECG Blog

APRIL 17, 2023

BOTTOM LINE: As per Dr. Meyers — the 2022 ACC Expert Consensus Decision Pathway for acute CP Management ( on Page 1933 in the J Am Coll Cardiol 2022 manuscript ) — now specifically includes deWinter T waves — as potential indication of "proximal LAD occlusion that warrants immediate angiography". See text ).

OR 52

OR STEMI ACS Emergency Department 52

Dr. Smith's ECG Blog

JULY 14, 2023

As I emphasized in My Comment at the bottom of the page in the October 10, 2022 post in Dr. Smith's ECG Blog — Interpretation of a post-resuscitation ECG can be extremely challenging. Many of these patients have preexisting coronary and other forms of severe heart disease. First — Some thoughts on the post -resuscitation ECG.

E-9-1-1 88

E-9-1-1 Defibrillator CPR STEMI 88

Dr. Smith's ECG Blog

DECEMBER 12, 2022

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!" Posterior reperfusion T waves, for example, would be T wave inversions on posterior leads, and manifest reciprocally in V1-V3 as abnormally tall anterior T waves.

OR 52

OR ACS STEMI Coronary 52

Dr. Smith's ECG Blog

JUNE 1, 2022

Moreover, the research which appears to confirm this idea was indeed in relation to the circumflex, but they did not study Occlusion ; rather, they studied asymptomatic coronary disease. I showed conclusively that this is a common finding in normal ECGs, though it is more common in LAD Occlusion than in norml variant STE.

STEMI 52

STEMI Coronary OR ALS 52

FOAMfrat

JUNE 25, 2024

Other risk factors include heavy physical exertion, alcohol consumption, dehydration, and existing co-morbidities that may affect acclimatization such as coronary artery disease, COPD, hypertension, obesity, and sickle cell trait/anemia. 2. Jensen JD, Vincent AL. Updated 2022 Dec 22]. Accessed 22 June 2024. www.nps.gov.

OR 97

OR Coronary ALS 97

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). A baby formula milk shortage for adults.” 11 Table 1.

E-9-1-1 73

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

Dr. Smith's ECG Blog

MARCH 6, 2023

Reference: • Writing Committee, Kontos MC, de Lemos JA, et al. 2022 ACC expert consensus decision pathway on the evaluation and disposition of acute chest pain in the emergency department: A report of the American college of cardiology solution set oversight committee. • They did, but had not recognized it. 2022.08.750 Section 5.2.2,

OR 52

OR STEMI ED Critical Care 52

Dr. Smith's ECG Blog

OCTOBER 6, 2023

de Winter et al in N Engl J Med 359:2071-2073, 2008. Answers might be forthcoming — IF we had a prior ( baseline ) ECG — and/or if we knew whether the patient had prior coronary disease ( perhaps with some unusual collateralization pattern ). Figure-1: The de Winter T Wave Pattern , as first described by Robbert J.

ALS 70

ALS Coronary OR 70

Dr. Smith's ECG Blog

JANUARY 15, 2023

Acute 100% coronary occlusion can be VERY subtle on the ECG. Hillinger et al. LA-LL Lead Reversal: We periodically show cases with technical mishaps that often go unnoticed ( Please see My Comment at the bottom of the page of the August 17, 2022 post in Dr. Smith's ECG Blog for a series of links with illustrative cases ).

Coronary 52

Coronary ALS OR 52

Dr. Smith's ECG Blog

DECEMBER 6, 2022

deWinter waves can happen in any coronary artery: see this case and this case = Comment by K EN G RAUER, MD ( 12/6 /2022 ): = Important case for discussion by Dr. McLaren — in that today's patient had a definite MI but no chest pain. Hyperacute T waves and reciprocal change can help identify STEMI(-)OMI 5.

STEMI 52

STEMI ACS Coronary OR 52