2022 and Coronary - Paramedicine Now

SGEM#370: Listen to your Heart (Score)…MACE Incidence in Non-Low Risk Patients with known Coronary Artery Disease

The Skeptics' Guide to EM

JULY 2, 2022

Date: June 30th, 2022 Reference: McGinnis et al. Major adverse cardiac event rates in moderate-risk patients: Does prior coronary disease matter? AEM June 2022. Date: June 30th, 2022 Reference: McGinnis et al. Major adverse cardiac event rates in moderate-risk patients: Does prior coronary disease matter?

Coronary

Coronary Heart Attack ACS CAD

What does the angiogram show? The Echo? The CT coronary angiogram? How do you explain this?

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. CORONARY ARTERIES: Exam was not directly tailored for coronary artery evaluation, noting recent diagnostic coronary angiogram.

Coronary

Coronary E-9-1-1 STEMI ACS

ECG of the Week 30th November 2022

EMergucate

NOVEMBER 28, 2022

She thinks she may have had stenting to her coronaries but … A 52 year old woman is triaged as a category 2 after complaining of chest tightness on the background of having previous cardiac history.

Coronary

OMI in a pediatric patient? Teenagers do get acute coronary occlusion, so don't automatically dismiss the idea.

Dr. Smith's ECG Blog

DECEMBER 5, 2023

Acute coronary syndrome in a pediatric patient? Ultimately, cardiac cath was done — revealing patent coronary arteries. I've listed potential causes of acute pericarditis in My Comment at the bottom of the page in the June 11, 2022 post in Dr. Smith's ECG Blog. Smith : this was the prudent thing to do!!

Coronary

Coronary CAD ACS ALS

Clinical Conundrum: Should a Troponin Routinely be Ordered in Patients with SVT?

REBEL EM

SEPTEMBER 21, 2023

What Your Gut Says: The patient has a tachydysrhythmia which may be the presentation of acute coronary syndrome (ACS) even though the patient has no ischemic symptoms. Up to 80% of patients will have at least one troponin sent ( Gabrielli 2022 ). Type 2: MI secondary to ischaemia, but not related to coronary atherosclerosis.

Coronary

Coronary ACS ED OR

ECG Pointers: STEMI Equivalents from the American College of Cardiology

EMDocs

DECEMBER 11, 2023

Emergency physicians have recognized for some time that there are many occlusions of the coronary arteries that do not present with classic STEMI criteria on the ECG. In October 2022, the American College of Cardiology released an updated expert consensus decision regarding the evaluation of chest pain in the emergency department.

STEMI

STEMI Coronary Emergency Department OR

Chest pain: Are these really "Nonspecific ST-T wave abnormalities", as the cardiologist interpretation states?

Dr. Smith's ECG Blog

MAY 27, 2024

1] But there are multiple other abnormalities that make this ECG diagnostic of Occlusion MI, localized likely to the right coronary artery: 1. Inferior hyperacute T waves, which have been added to the 2022 ACC consensus on chest pain as a “STEMI equivalent”[3] 3. J Am Coll Cardiol 2022 4. De Alencar Neto. Int J Cardiol 2024 2.

STEMI

STEMI Coronary ALS Emergency Department

60 year old with chest pain, STEMI negative. What should the discharge diagnosis be?

Dr. Smith's ECG Blog

JULY 7, 2024

First trop was 7,000ng/L (normal 25% of ‘Non-STEMI’ patients with delayed angiography have the exact same pathology of acute coronary occlusion. The new ACC expert consensus explains that: “STEMI ECG criteria on a standard 12-lead ECG alone will miss a significant minority of patients who have acute coronary occlusion. Take home 1.

STEMI

STEMI Coronary ALS OR

VF arrest at home, no memory of chest pain. Angiography non-diagnostic. Does this patient need an ICD? You need all the ECGs to know for sure.

Dr. Smith's ECG Blog

JUNE 23, 2024

The patient was treated as possible NSTEMI and underwent coronary angiography about 4 hours after presentation. TIMI 3 means the rate of passage of dye through the coronary artery is normal by angiography.) Initial hsTnI was 384 ng/L. The report describes a 60% proximal LAD lesion with TIMI 3 flow.

Coronary

Coronary CAD CPR Critical Care

Chest pain, resolved. Does it need emergent cath lab activation (some controversy here)? And much much more.

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. Total coronary occlusion, if very brief, may have minimal infarction and yet be very dangerous. Am Heart J. 2000;139:430–436.

Coronary

Coronary STEMI ED OR

Is OMI an ECG Diagnosis?

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

STEMI Coronary ALS CAD

EM@3AM: Kawasaki Disease

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. UpToDate;2022. Accessed December 31, 2022. Accessed December 31, 2022. In: Post TW, ed. link] Ramphul, K., 2018; 3: e41-e45.

EMS

EMS Coronary ED OR

SAEM Clinical Images Series: A Case of Painful Skin Lesions

ALiEM

OCTOBER 20, 2023

A 50-year-old Caucasian female with a history of hypertension, coronary artery disease, and insulin-dependent diabetes mellitus presents to the emergency department with a complaint of painful sores on the top of her left foot. Updated 2022 Dec 1]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Necrobiosis Lipoidica.

Plasma

Plasma Coronary Emergency Department OR

High sensitivity cardiac troponins for ED chest pain evaluation (2022 ACC pathway)

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

E-9-1-1 ED Coronary ALS

emDOCs Podcast – Episode 86 Tricky Cases Part 2

EMDocs

SEPTEMBER 19, 2023

NSTEMI dichotomy is not sensitive for true occlusion MI or acute coronary occlusion. “The application of STEMI ECG criteria on a standard 12-lead ECG alone will miss a significant miry of patients who have acute coronary occlusion.” 2022 Nov 15;80(20):1925-1960. J Am Coll Cardiol.

STEMI

STEMI Coronary Emergency Department EMS

Texted from a former EM resident: 70 yo with syncope and hypotension, but no chest pain. Make their eyes roll!

Dr. Smith's ECG Blog

SEPTEMBER 11, 2024

Other cardiac-related causes for syncope associated with acute MI may include malignant ventricular arrhythmias and bradyarrhythmias including AV block.

EMS

EMS CPR ED Coronary

A 50-something with Regular Wide Complex Tachycardia: What to do if electrical cardioversion does not work?

Dr. Smith's ECG Blog

SEPTEMBER 19, 2023

Past medical history includes coronary stenting 17 years prior. Cardiology was consulted and the patient underwent coronary angiogram which showed diffuse severe three-vessel disease. Coronary angiogram shows diffuse severe three-vessel disease. Initial ED ECG: What do you think? IV Diltiazem was Contraindicated!

Coronary

Coronary OR EMS ED

75 year old with 24 hours of chest pain, STEMI negative

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

STEMI Coronary Paramedic ALS

Emergency vs Delayed Cath lab activation!

Emergency Medicine Education

APRIL 12, 2023

JAMA in July 2022 published a French national multicenter study regarding OHCA patient who had a ROSC to assess cerebral performance category. Link to article Early versus deferred coronary angiography following cardiac arrest. There is always a debate in the ED that should we send a patient status post ROSC to cath lab or not.

Coronary

Coronary ED OR

The REVIVED Trial: PCI in Patients with Severe Ischemic Left Ventricular Systolic Dysfunction?

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

Coronary ALS OR EMS

"The dye don't lie".except when it does. Angiogram Negative, or is it?

Dr. Smith's ECG Blog

SEPTEMBER 9, 2024

You can easily imagine this patient getting one of several diagnoses -- vasospasm, MINOCA , pericarditis, or maybe even no diagnosis at all beyond "non-obstructive coronary artery disease." Another option would be to use Optical Coherence Tomography for Coronary Imaging ). That plaque is at risk of thrombosing again.

OR

OR Coronary ACS EMS

A man in his early 40s with chest pain a "normal ECG" by computer algorithm. Should we avoid interrupting a physician to interpret his ECG?

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

STEMI Coronary Paramedic OR

Occlusion myocardial infarction is a clinical diagnosis

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

E-9-1-1 ACS Coronary STEMI

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

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. Incidence of an acute coronary occlusion. link] Harhash AA et al.

Coronary

Coronary ACS STEMI ALS

See OMI vs. STEMI philosophy in action

Dr. Smith's ECG Blog

DECEMBER 22, 2022

Smith , d and Muzaffer Değertekin a DIFOCCULT: DIagnostic accuracy oF electrocardiogram for acute coronary OCClUsion resuLTing in myocardial infarction. Coronary arteries cannot be assessed because the scan was not gated, but proximal segments of the coronary arteries seem to be open with some contrast. Again nothing diagnostic.

STEMI

STEMI EMR Coronary OR

What Lies Beneath

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

E-9-1-1 Coronary ALS ICU

emDOCs Podcast – Episode 94: GLP-1 Agonist Complications

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

Allergic Reaction ALS CAD OR

What would you do with acute chest pain and this ECG? You might see what the Queen thinks.

Dr. Smith's ECG Blog

JUNE 19, 2024

The ED provider ordered a coronary CT scan to assess the patient for CAD. The patient was taken emergently to the cath lab for a pericardiocentesis instead of a coronary angiogram. A troponin T was drawn at 1229 and resulted slightly elevated at 23 ng/L (URL for men in this assay is 15 ng/L).

STEMI

STEMI Coronary CAD ED

What are treatment options for this rhythm, when all else fails?

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

Defibrillator Coronary ALS STEMI

A 20-something with intermittent then acute chest pain

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

Coronary STEMI ALS OR

See this "NSTEMI" go unrecognized for what it really is, how it progresses, and what happens

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

The De Winter ECG pattern: morphology and accuracy for diagnosing acute coronary occlusion: systematic review. Published 2022 Feb 20. Immediate and early percutaneous coronary intervention in very high-risk and high-risk non-ST segment elevation myocardial infarction patients. 2022;Available from: [link] 7. 2022.01.006 6.

ACS

ACS Coronary ALS CAD

Two ECGs texted to me in the same hour. What would you recommend?

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

STEMI Coronary ACS OR

Another myocardial wall is sacrificed at the altar of the STEMI/NonSTEMI mass delusion (and Opiate pain relief).

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. It is one of the few OMI patterns that is really well described: de Winter’s T-waves. Am Heart J.

STEMI

STEMI Coronary ACS OR

Four patients with chest pain and ‘normal’ ECG: can you trust the computer interpretation?

Dr. Smith's ECG Blog

OCTOBER 18, 2023

6] Among 394 emergency department Code STEMI patients with acute culprit lesion requiring coronary interpretation, 16 (4.1%) presented with an ECG labeled ‘normal’ or ‘otherwise normal’ by computer interpretation. 2022 ; 51 : 384 - 387 3. 2022 ; 55 : 180 - 182 6. Am J Emerg Med. J Electrocardiol. 2019 ; 54 : 79 - 81.

STEMI

STEMI Emergency Department Coronary OR

Palpitations while awaiting CABG

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". Written by Willy Frick A 57 year old man with was admitted to the hospital with chest pain. The rhythm terminated before it could be captured on 12-lead.

Defibrillator

Defibrillator ALS Coronary OR

Why the sudden shock after a few days of malaise?

Dr. Smith's ECG Blog

SEPTEMBER 5, 2024

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. This does not fit with the clinical scenario in today's case. Below are two more video files.

STEMI

STEMI Coronary OR ALS

A man in his 70s with acute chest pain and paced rhythm.

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

STEMI Coronary ED ACS

A 50-something with acute chest pain, a computer "Normal" ECG, and a HEART score of 3 (low risk)

Dr. Smith's ECG Blog

APRIL 29, 2023

As a visual aid to facilitate recognition of the ST-T wave changes characteristic of acute posterior MI — I favor the Mirror Test ( See My Comment at the bottom of the page in the September 21, 2022 post in Dr. Smith's ECG Blog ). Clinicallly — this would be consistent with the less-than-total coronary occlusion seen on cath.

Critical Care

Critical Care Coronary ED OR

50-year old with chest pain, “no ischemic changes”

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. Am J Emerg Med 2023 2.

STEMI

STEMI Coronary OR ALS

A Middle Aged Male diagnosed with Gastroesophageal Reflux

Dr. Smith's ECG Blog

JULY 16, 2022

This illustration comes from Charles Bruen's great blog, Resus Review Coronary Artery Diagramming – Resus Review Charles is another illustrious graduate of the Hennepin EM Residency; actually, the EM/IM combined residency. This middle-aged male with known coronary disease presented with new chest pain.

Coronary

Coronary ED EMS Critical Care

Chest pain and shock: Is there a right ventricular OMI on this ECG? And should he undergo trancutaneous pacing?

Dr. Smith's ECG Blog

MAY 30, 2023

Methods Retrospective study of consecutive inferior STEMI , comparing ECGs of patients with, to those without, RVMI, as determined by angiographic coronary occlusion proximal to the RV marginal branch. METHODS: We studied 267 patients with recanalized IMI due to the right coronary artery (RCA) occlusion within 6h after symptom onset.

E-9-1-1

E-9-1-1 STEMI Coronary OR

Sometimes even ST Elevation meeting criteria is not enough to be convincing

Dr. Smith's ECG Blog

NOVEMBER 13, 2022

Take home messages: Any coronary occlusion may present with vague symptoms, but when ECG is clear, there should not be any suspicion. 2022 Mar-Apr;71:44-46. Epub 2022 Jan 31. PMID: 34523597. == MY Comment by K EN G RAUER, MD ( 11/13/2022 ): == Highly interesting case by Emre Aslanger. ECG hardly ever tells lies!

EMR

EMR Coronary OR STEMI

Pulsus Alternans and the Menacing Metronome

FOAMfrat

JUNE 30, 2023

This includes cardiomyopathy, aortic stenosis, and coronary artery disease." (2) Updated 2022 Aug 7]. Relation between pulsus alternans and transient occlusion of the left anterior descending coronary artery. Left ventricular alternans occur in the setting of severe left ventricular dysfunction. Henery D, Tummala R. Parmley, W.

Coronary

Coronary OR EMS

75 year old dialysis patient with nausea, vomiting and lightheadedness

Dr. Smith's ECG Blog

AUGUST 19, 2023

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

STEMI ACS OR ALS

SGEM#370: Listen to your Heart (Score)…MACE Incidence in Non-Low Risk Patients with known Coronary Artery Disease

What does the angiogram show? The Echo? The CT coronary angiogram? How do you explain this?

Trending Sources

ECG of the Week 30th November 2022

OMI in a pediatric patient? Teenagers do get acute coronary occlusion, so don't automatically dismiss the idea.

Clinical Conundrum: Should a Troponin Routinely be Ordered in Patients with SVT?

ECG Pointers: STEMI Equivalents from the American College of Cardiology

Chest pain: Are these really "Nonspecific ST-T wave abnormalities", as the cardiologist interpretation states?

60 year old with chest pain, STEMI negative. What should the discharge diagnosis be?

VF arrest at home, no memory of chest pain. Angiography non-diagnostic. Does this patient need an ICD? You need all the ECGs to know for sure.

Chest pain, resolved. Does it need emergent cath lab activation (some controversy here)? And much much more.

Is OMI an ECG Diagnosis?

EM@3AM: Kawasaki Disease

SAEM Clinical Images Series: A Case of Painful Skin Lesions

High sensitivity cardiac troponins for ED chest pain evaluation (2022 ACC pathway)

emDOCs Podcast – Episode 86 Tricky Cases Part 2

Texted from a former EM resident: 70 yo with syncope and hypotension, but no chest pain. Make their eyes roll!

A 50-something with Regular Wide Complex Tachycardia: What to do if electrical cardioversion does not work?

75 year old with 24 hours of chest pain, STEMI negative

Emergency vs Delayed Cath lab activation!

The REVIVED Trial: PCI in Patients with Severe Ischemic Left Ventricular Systolic Dysfunction?

"The dye don't lie".except when it does. Angiogram Negative, or is it?

A man in his early 40s with chest pain a "normal ECG" by computer algorithm. Should we avoid interrupting a physician to interpret his ECG?

Occlusion myocardial infarction is a clinical diagnosis

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

See OMI vs. STEMI philosophy in action

What Lies Beneath

emDOCs Podcast – Episode 94: GLP-1 Agonist Complications

What would you do with acute chest pain and this ECG? You might see what the Queen thinks.

What are treatment options for this rhythm, when all else fails?

A 20-something with intermittent then acute chest pain

See this "NSTEMI" go unrecognized for what it really is, how it progresses, and what happens

Two ECGs texted to me in the same hour. What would you recommend?

Another myocardial wall is sacrificed at the altar of the STEMI/NonSTEMI mass delusion (and Opiate pain relief).

Four patients with chest pain and ‘normal’ ECG: can you trust the computer interpretation?

Palpitations while awaiting CABG

Why the sudden shock after a few days of malaise?

A man in his 70s with acute chest pain and paced rhythm.

A 50-something with acute chest pain, a computer "Normal" ECG, and a HEART score of 3 (low risk)

50-year old with chest pain, “no ischemic changes”

A Middle Aged Male diagnosed with Gastroesophageal Reflux

Chest pain and shock: Is there a right ventricular OMI on this ECG? And should he undergo trancutaneous pacing?

Sometimes even ST Elevation meeting criteria is not enough to be convincing

Pulsus Alternans and the Menacing Metronome

75 year old dialysis patient with nausea, vomiting and lightheadedness

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