2022 and Coronary - Paramedicine Now

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

Dynamic OMI ECG. Negative trops and negative angiogram does not rule out coronary ischemia or ACS.

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

Compensatory enlargement was defined as being present when the total coronary arterial cross-sectional area at the stenotic site was greater than that at the proximal nonstenotic site. We documented that the majority of stenotic lesions had compensatory enlargement and thus exhibited remodeling. As was emphasized by Dr.

Coronary

Coronary ACS OR EMR

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

Contrast Media Shortage of 2022 – Lessons Learned

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

E-9-1-1 Emergency Department ALS ED

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

A 30-something woman with intermittent CP, a HEART score of 2 and a Negative CT Coronary Angiogram on the same day

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

Coronary STEMI CAD 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

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

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

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

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

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

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

SGEM#367: GRACE2 – Low-Risk, Recurrent Abdominal Pain

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

Emergency Department ACS ALS Coronary

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 ICU

Acute artery occlusion -- which one?

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

Thanks in part to rapid bedside diagnosis, the patient was able to avoid emergent coronary angiography. Consider the following: We become attuned to looking for acute coronary occlusion in patients who present with acute symptoms to the ED ( E mergency D epartment ).

E-9-1-1

E-9-1-1 Coronary STEMI ALS

Prehospital activation: De-activated on ED arrival by Cardiologist because "It's not a STEMI"

Dr. Smith's ECG Blog

OCTOBER 27, 2024

Initial 4th generation troponin I was 10 ng/mL is consistent with large MI due to acute coronary occlusion (OMI). There are moderate coronary artery calcifications. Immediate and early percutaneous coronary intervention in very high-risk and high-risk non-ST segment elevation myocardial infarction patients.

STEMI

STEMI ED Coronary EMS

Why you should use the Queen of Hearts and record serial ECGs more often. If you wait for troponin.

Dr. Smith's ECG Blog

OCTOBER 22, 2024

The coronary angiography showed a 100% ostial main (obtuse) marginal occlusion!" Dominant right coronary, atherosclerotic and calcified. Presence of a single coronary lesion: occlusion of the ostial main marginal.

Coronary

Coronary STEMI OR ALS

Cath Lab occupied. Which patient should go now (or does only one need it? Or neither?)

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

OR STEMI Coronary ED

50 yo with V fib has ROSC, then these 2 successive ECGs: what is the infarct artery?

Dr. Smith's ECG Blog

SEPTEMBER 29, 2024

Although predicting the "culprit" artery of acute coronary occlusion is often straightforward ( ie, based on the distribution of leads with ST elevation and leads with reciprocal ST depression ) — this is not always the case. The April 8, 2022 post by Drs. See Discussion in the June 29, 2024 post of Dr. Smith' ECG Blog ).

STEMI

STEMI Coronary Defibrillator OR

Acute OMI or "Benign" Early Repolarization?

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

E-9-1-1 OR Coronary ACS

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

What do you suspect from this ECG in this 40-something with SOB and Chest pain?

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

Coronary STEMI EMS 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

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

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 30-something with acute chest pain

Dr. Smith's ECG Blog

OCTOBER 3, 2024

Coronaries were clean. There ARE Signs of a Repolarization Variant: Among the many posts in which we've reviewed cases of repolarization variants — is the May 23, 2022 post. If a final test was perceived as "needed" — perhaps a normal coronary CT angiogram could have helped to avoid cardiac catheterization.

E-9-1-1

E-9-1-1 Coronary ALS ED

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

Updates in the Management of Refractory Ventricular Tachycardia or Ventricular Fibrillation Arrest

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. Heart disease and stroke statistics-2022 update: A report from the American Heart Association.

Defibrillator

Defibrillator OR ALS Epinephrine

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

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting."

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

Emergency Department E-9-1-1 Coronary STEMI

Medical Malpractice Insights: Radiology over-reads – Who’s responsible?

EMDocs

SEPTEMBER 26, 2024

Autopsy shows coronary atherosclerosis and marked cardiomegaly with a thickened left ventricular wall. 3 : September 2022. An unknown EP reviews the report, determines that there is no reason to notify the patient, and documents nothing. Tyler W et al. Volume 80, no. appeared first on emDOCs.net - Emergency Medicine Education.

Emergency Department

Emergency Department ED ALS Coronary

A fascinating electrophysiology case. What is this wide complex tachycardia, and how best to manage it?

Dr. Smith's ECG Blog

JANUARY 9, 2024

The patient is an older woman with known coronary disease and an ICD-Pacemaker implanted because of a history of VT ( V entricular T achycardia ). In this case report — the 69-year old woman ( who incidently had a history of both coronary disease and cardiomyopathy ) — remained in sustained VT for 5 days without hemodynamic deterioration.

Coronary

Coronary ACS ED OR

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

The EMERGE Trial: Emergency vs Delayed Catheterization in Survivors of Out-of-Hospital Cardiac Arrest

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. JAMA Cardiol.

Coronary

Coronary CPR OR ICU

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

"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

Case Report: The Not So Normal, Normal EKG

ACEP Now

AUGUST 12, 2024

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

Emergency Department

Emergency Department STEMI ACS ED

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

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

Dynamic OMI ECG. Negative trops and negative angiogram does not rule out coronary ischemia or ACS.

Trending Sources

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?

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.

Contrast Media Shortage of 2022 – Lessons Learned

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

A 30-something woman with intermittent CP, a HEART score of 2 and a Negative CT Coronary Angiogram on the same day

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?

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.

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

EM@3AM: Kawasaki Disease

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

SAEM Clinical Images Series: A Case of Painful Skin Lesions

Is OMI an ECG Diagnosis?

SGEM#367: GRACE2 – Low-Risk, Recurrent Abdominal Pain

emDOCs Podcast – Episode 86 Tricky Cases Part 2

Acute artery occlusion -- which one?

Prehospital activation: De-activated on ED arrival by Cardiologist because "It's not a STEMI"

Why you should use the Queen of Hearts and record serial ECGs more often. If you wait for troponin.

Cath Lab occupied. Which patient should go now (or does only one need it? Or neither?)

50 yo with V fib has ROSC, then these 2 successive ECGs: what is the infarct artery?

Acute OMI or "Benign" Early Repolarization?

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

What do you suspect from this ECG in this 40-something with SOB and Chest pain?

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

Emergency vs Delayed Cath lab activation!

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

A 30-something with acute chest pain

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?

Updates in the Management of Refractory Ventricular Tachycardia or Ventricular Fibrillation Arrest

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?

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting."

Medical Malpractice Insights: Radiology over-reads – Who’s responsible?

A fascinating electrophysiology case. What is this wide complex tachycardia, and how best to manage it?

See OMI vs. STEMI philosophy in action

The EMERGE Trial: Emergency vs Delayed Catheterization in Survivors of Out-of-Hospital Cardiac Arrest

What Lies Beneath

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

Case Report: The Not So Normal, Normal EKG

emDOCs Podcast – Episode 94: GLP-1 Agonist Complications

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