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 143

Coronary ACS ED OR 143

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. Out-of-hospital cardiac arrest is a commonly encountered entity in U.S.

Defibrillator 98

Defibrillator OR ALS Epinephrine 98

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

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 66

OR Coronary ACS EMS 66

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 110

STEMI Coronary Emergency Department OR 110

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

OCTOBER 8, 2024

In the context of this woman in her 60s who has known coronary disease ( and who is now presenting with acute chest discomfort ) — I interpreted neighboring leads V1 and V2 as part of the same acute process suggested by the QRST in lead V3. For more on Precordial Swirl — See the October 15, 2022 post in Dr. Smith's ECG Blog ).

OR 108

OR STEMI ICU Coronary 108

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 119

STEMI Coronary ALS Emergency Department 119

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 161

Plasma Coronary Emergency Department OR 161

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. Pattern A evolves into Pattern B. Am Heart J. 2000;139:430–436. Am J Cardiol.

Coronary 117

Coronary STEMI ED OR 117

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. But does this matter?

STEMI 118

STEMI Coronary ALS CAD 118

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.

EMS 65

EMS Coronary ED OR 65

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 66

STEMI Coronary ALS OR 66

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!" In other words, to get from hyperacute T waves and STE to terminal T wave inversion, the ST and T wave must pass transiently through a state of near-normal.

OR 52

OR ACS STEMI Coronary 52

Dr. Smith's ECG Blog

NOVEMBER 29, 2023

This new ECG was still interpreted as STEMI and the patient was taken to the cath lab where the angiogram showed completely normal coronary arteries throughout. Smith : this ECG is definitely not OMI, but could be mistaken for Swirl pattern, which is a septal OMI with STE in V1 and STD in V6. Unfortunately no echo was available.

OR 116

OR STEMI EMS ED 116

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 108

Coronary CAD CPR Critical Care 108

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.” NCSE is likely more common than we think.

STEMI 72

STEMI Coronary Emergency Department ICU 72

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

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 80

STEMI Coronary Defibrillator OR 80

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. You must record frequent serial ECGs for patients with chest pain. Every 15 minutes! R wave progression is normal.

Coronary 66

Coronary STEMI OR ALS 66

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 116

STEMI ED Coronary EMS 116

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 ALS ACS Coronary 100

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 ). What do you do clinically when the ECG looks like this?

E-9-1-1 110

E-9-1-1 Coronary STEMI ALS 110

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? Why did I say that?

Coronary 136

Coronary OR EMS ED 136

Dr. Smith's ECG Blog

DECEMBER 11, 2023

For the same reason, you should not delay coronary angiography because pain resolves with morphine. When I see this, I always look at V2 for any evidence of posterior OMI (STD, or loss or inversion of T-wave, or downsloping ST segment: there is a negative T-wave ), and V6 for any STE (normal). So I would be worried about inferior OMI.

E-9-1-1 121

E-9-1-1 ACS Coronary STEMI 121

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. Real or just fake?"

E-9-1-1 111

E-9-1-1 Coronary ALS ED 111

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". QOH: "Not OMI, High confidence."

OR 52

OR STEMI ACS Emergency Department 52

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. by being interrupted??? 2021.11.023.

STEMI 90

STEMI Coronary Paramedic OR 90

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. No d-dimer or CT pulmonary angiogram was done when they discovered that she had normal coronary arteries. I discussed all results with patient. What was the actual diagnosis?

Coronary 71

Coronary STEMI EMS OR 71

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

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. Plaintiff : You told me you would call me if the radiology report was “different.” Tyler W et al.

Emergency Department 74

Emergency Department ED ALS Coronary 74

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 40

Coronary ED OR 40

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. The "good news" — is that a cardiac-related cause of syncope is unlikely if the initial ECG is normal, and cardiac monitoring in the ED fails to reveal significant arrhythmia.

EMS 106

EMS CPR ED Coronary 106

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 ). However , this patient is having chest discomfort, and by definition then she should be considered not to be stable. Is this: 1. In either case, prompt cardioversion is indicated.

Coronary 99

Coronary ACS ED OR 99

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. A 12 Lead ECG was recorded secondary to bizarre telemetry findings at bedside.

E-9-1-1 130

E-9-1-1 Coronary ALS ICU 130

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 83

Coronary CPR OR ICU 83

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 52

Coronary ACS STEMI ALS 52