Dr. Smith's ECG Blog

DECEMBER 11, 2023

For the same reason, you should not delay coronary angiography because pain resolves with morphine. Both the outdated 2014 AHA/ACC guidelines and the updated 2023 ESC guidelines recommend immediate invasive management of patients with uncontrolled chest pain. 2023 ESC guidelines for the management of acute coronary syndromes.

E-9-1-1 119

E-9-1-1 ACS Coronary STEMI 119

Dr. Smith's ECG Blog

JUNE 17, 2024

showed that among patients with either acute coronary syndrome or acute pulmonary embolism and negative T waves in the precordial leads (V1-V4), that inverted T waves in leads III and V1 were present in only 1% of patients with acute coronary syndrome and 88% of patients with pulmonary embolism. In fact, Kosuge et al. Kosuge et al.

E-9-1-1 134

E-9-1-1 ACS Emergency Department ALS 134

Don't Forget the Bubbles

OCTOBER 7, 2024

However, vertical flow can result in myocardial injury secondary to coronary artery spasm. This is supplied via alternating current (AC), increasing the risk of titanic contraction of skeletal muscle, leading to kids holding on to the electrical power source. AC and DC shocks may result in different injury patterns. Culnan, D.M.,

ACS 80

ACS Life Support OR CPR 80

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. A Bayesian approach to acute coronary occlusion.

STEMI 114

STEMI Coronary ALS CAD 114

ACEP Now

DECEMBER 11, 2023

Many conditions outside of acute coronary syndrome (ACS) mimic ST-elevation myocardial infarction (STEMI), but only a handful of cases have reported ST-elevations (STE) in the setting of pancreatic inflammation where underlying ACS was excluded. 2 Proposed hypothesis as described by Hsu et al., Click to enlarge.)

STEMI 52

STEMI Coronary ACS Critical Care 52

Dr. Smith's ECG Blog

DECEMBER 19, 2023

The commonest causes of MINOCA include: atherosclerotic causes such as plaque rupture or erosion with spontaneous thrombolysis, and non-atherosclerotic causes such as coronary vasospasm (sometimes called variant angina or Prinzmetal's angina), coronary embolism or thrombosis, possibly microvascular dysfunction. This is not the case.

E-9-1-1 113

E-9-1-1 Coronary ACS BLS 113

Dr. Smith's ECG Blog

APRIL 9, 2024

ACS then becomes less likely. Before the lab values returned this patient had a n emergent coronary CT angiogram done that ruled out CAD. A false positive cath lab activation is also off course acceptable for this diagnosis if you cannot get an emergent coronary CT angiogram. There are no coronary stenoses.

Coronary 85

Coronary CAD ACS OR 85

Dr. Smith's ECG Blog

MARCH 1, 2023

This pattern occurs regardless of whether the cause is ACS (decreased supply) or any other cause of decreased supply or increased demand. You must understand that this pattern does not differentiate ACS from other causes of supply/demand mismatch.

Allergic Reaction 52

Allergic Reaction E-9-1-1 Epinephrine Coronary 52

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. For more on MINOCA — See My Comment in the November 16, 2023 post in Dr. Smith's ECG Blog ). As was emphasized by Dr.

Coronary 110

Coronary ACS OR EMR 110

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

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. 2009;95:1701–1706.

ACS 85

ACS Coronary ALS CAD 85

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

References: 1) See this study showing an association between morphine and mortality in Non-STE-ACS: Meine TJ, Roe M, Chen A, Patel M, Washam J, Ohman E, Peacock W, Pollack C, Gibler W, Peterson E. Association of intravenous morphine use and outcomes in acute coronary syndromes: Results from the CRUSADE Quality Improvement Initiative.

E-9-1-1 80

E-9-1-1 ACS STEMI Coronary 80

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

More past history: hypertension, tobacco use, coronary artery disease with two vessel PCI to the right coronary artery and circumflex artery several years prior. This is diagnostic of ACS; it appears to be a reperfused acute inferior OMI. It is unknown when this pain recurred and became constant.

Defibrillator 126

Defibrillator Coronary STEMI CPR 126

Dr. Smith's ECG Blog

JANUARY 27, 2024

There were zero patients in this study with a "normal" ECG who had any kind of ACS! Old ‘NSTEMI’ A history of coronary artery disease and a stent to the same territory further increases pre-test likelihood of acute coronary occlusion, including in-stent thrombosis. So this study is actually worthless.

STEMI 96

STEMI Coronary ACS ED 96

Dr. Smith's ECG Blog

JULY 27, 2023

I did not think it was due to ACS, but we ordered an ED ECG immediately: What do you think? But in this case the clinical scenario is not right for acute ACS with OMI, and there is very high voltage, and the patient is very young, (though beware of young patients , even 29 year olds!! I was not worried for a coronary etiology.

Coronary 52

Coronary ACS Naloxone Plasma 52

Dr. Smith's ECG Blog

MAY 31, 2023

-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. Association of intravenous morphine use and outcomes in acute coronary syndromes: Results from the CRUSADE Quality Improvement Initiative.

STEMI 73

STEMI Coronary ACS OR 73

Dr. Smith's ECG Blog

MARCH 13, 2023

This is acute ACS, but it almost always seen in a pain free state. My Comment by K EN G RAUER, MD ( 3/13 /2023 ): = Today's case illustrates optimal clinical use of a pre-hospital Wellens' pattern for understanding the evolution of acute OMI. An ED ECG, if recorded with pain, should show LAD OMI.

ED 52

ED ACS Coronary Paramedic 52

Dr. Smith's ECG Blog

APRIL 14, 2023

It is easy to say this in retrospect, especially not being the one in charge of this overcrowded waiting room full of unseen patients, but an elderly patient with known CAD and ongoing ACS-sounding chest pain despite medical management with positive troponin is already an indication for emergent cath, regardless of the ECG!

CAD 52

CAD ACS STEMI Coronary 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 such exceptions — See My Comment in the January 9, 2019 — August 22, 2020 — and June 30, 2023 posts in Dr. Smith's ECG Blog ). Some patients do this.

E-9-1-1 101

E-9-1-1 Coronary EMS ED 101

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. Accessed April 13, 2023.

EMS 74

EMS ALS OR ACS 74

Dr. Smith's ECG Blog

MAY 8, 2023

Electrocardiographic Diagnosis of Acute Coronary Occlusion Myocardial Infarction in Ventricular Paced Rhythm Using the Modified Sgarbossa Criteria. Immediate ECG diagnosis of an acute coronary lesion resulting in occlusion myocardial infarction is critical in the modern reperfusion era. Annals of Emergency Medicine 2021.

STEMI 52

STEMI Coronary ED ACS 52

Dr. Smith's ECG Blog

SEPTEMBER 24, 2023

I showed this to some of my colleagues and they were not able to confidently say that this is an acute coronary occlusion. Guidelines say that if a patient has ACS but refractory pain, the patient should go emergently to the cath lab. Back to the case. Initial troponin I returned elevated at 84 ng/L (ref value <34 ng/L).

STEMI 88

STEMI Coronary ACS OR 88

Dr. Smith's ECG Blog

JANUARY 5, 2024

Thus, these troponins are very concerning for ACS, and subsequent ones will probably be diagnostic of acute MI. We know that even high-sensitivity troponin may not exceed the "normal" range for a period of hours in certain patients with acute coronary occlusion. The troponin is trapped in the myocardium that is not being perfused.

ACS 101

ACS ALS OR STEMI 101

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 78

STEMI ACS OR ALS 78

Dr. Smith's ECG Blog

APRIL 4, 2023

Fortunately, Dr. Cho was not looking for STEMI ECG criteria but for an acute coronary occlusion. As he documented, “This patient is experiencing chest pain consistent with an acute coronary syndrome. Start using the terms acute coronary occlusion and occlusion MI. That’s exactly what happened in this case.

STEMI 52

STEMI Coronary OR ACS 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

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. My Comment by K EN G RAUER, MD ( 1/23 /2023 ): = The importance of today's case by Drs. Its course is variable, often supplying the lateral wall of the LV.

ACS 52

ACS Coronary Defibrillator STEMI 52

EMDocs

JANUARY 11, 2024

Author: Brit Long, MD (@long_brit) // Reviewed by Alex Koyfman, MD (@EMHighAK) The American Heart Association (AHA) and Neurocritical Care Society (NCS) released their 2023 Scientific Statement on the critical care management of post ROSC patients. 2023 Dec 1. Administer VTE prophylaxis in the first 48 hours, preferably LMWH.

Critical Care 75

Critical Care E-9-1-1 OR ICU 75

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

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

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-9-1-1 111

E-9-1-1 OR Coronary ACS 111

Dr. Smith's ECG Blog

MAY 3, 2024

RBBB + LAFB in the setting of ACS is very bad. Some patients have baseline RBBB with LAFB, but in patients with likely ACS, these are associated with severe infarction with cardiac arrest, cardiogenic shock or impending shock. Patients with ACS and RBBB/LAFB usually have a left main vs. proximal LAD. Learning Points: 1.

ACS 108

ACS ED Coronary EMS 108

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 95

Coronary ACS ED OR 95

Dr. Smith's ECG Blog

JANUARY 6, 2023

Immediate and early percutaneous coronary intervention in very high-risk and high-risk Non-STEMI patients. Smith comment: We have shown that use of opiates is associated with worse outcomes in ACS: Bracey, A. Opioids in ACS may reduce the pain score, but do not provide reperfusion for ongoing ACS. Lupu L, et al.

ACS 52

ACS Coronary ICU STEMI 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. 2023 May 2;15(5):e38428. Normalization of abnormal T waves in ischemia. Arch Intern Med.

Emergency Department 52

Emergency Department STEMI ACS ED 52

REBEL EM

JANUARY 29, 2024

Click here for Direct Download of the Podcast Paper: Aykan AC et al. Clin Exp Emerg Med 2023. PMID: 23102885 Aykan AC et al. Clin Exp Emerg Med 2023. REBEL Cast Ep123: Reduced-Dose Systemic Peripheral Alteplase in Massive PE? Reduced-Dose Systemic Fibrinolysis in Massive Pulmonary Embolism: A Pilot Study.

ALS 136

ALS ACS OR CPR 136

Dr. Smith's ECG Blog

NOVEMBER 1, 2023

I assumed it was from a patient with symptoms compatible with ACS/OMI. If you are convinced by all the data, including the troponin, that the patient's pain is due to ACS, and he has persistent pain, then he should go to the cath lab. This ECG was texted to me by a colleague. What do you think? J Am Heart Assoc.

ACS 114

ACS ALS OR STEMI 114