REBEL EM

JUNE 1, 2023

Article: Branch KHR et al. Resus 2023. Indication for emergency invasive coronary angiography or had coronary angiography within 1 hour of arrival. Known obstructive coronary artery disease or known coronary stent. References: Branch KHR et al. Resus 2023. Known cardiac defibrillator.

Coronary 145

Coronary Defibrillator CPR ALS 145

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. Amsterdam et al. Alencar et al.

STEMI 114

STEMI Coronary ALS CAD 114

Dr. Smith's ECG Blog

OCTOBER 3, 2024

Coronaries were clean. Not OMI with High Confidence Click here to sign up for Queen of Hearts Access We showed that the Queen of Hearts decreases false positive cath lab activations: 1) Published recently in Prehospital Emergency Care Baker PO et al. 2) To be presented at AHA conference in Chicago in 2 weeks: Sharkey SW et al.

E-9-1-1 105

E-9-1-1 Coronary ALS ED 105

REBEL EM

SEPTEMBER 14, 2023

Zeymer HT et al. References: Zeymer HT et al. The benefits of this strategy may be outweighed by the risk of the device-related complications (i.e. bleeding, stroke, limb ischemia, and hemolysis). The evidence for this practice has been sparse until now. Extracorporeal Life Support in Infarct-Related Cardiogenic Shock. Control: 53.4%

Life Support 136

Life Support Coronary CPR ICU 136

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 68

STEMI Coronary ALS OR 68

Dr. Smith's ECG Blog

JUNE 17, 2024

In fact, Kosuge et al. 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. “The

E-9-1-1 134

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

REBEL EM

SEPTEMBER 28, 2023

Paper: Van de Werf, F et al. STREAM-2: Half-Dose Tenecteplase or Primary Percutaneous Coronary Intervention in Older Patients With ST-Segment-Elevation Myocardial Infarction: A Randomized, Open-Label Trial. References: Van de Werf, F et al. PMID: 37439219 Armstrong P et al.

STEMI 137

STEMI Allergic Reaction Coronary Ambulance 137

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., Accessed November 29, 2023.

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

JUNE 14, 2024

He underwent coronary angiography which showed severe multivessel disease, and he agreed to proceed with workup for CABG. The September 15, 2023 post — for PTA ( Pulse-Tap Artifact ). The April 6, 2023 post — excessive baseline artifact misdiagnosed as AFib ( instead of sinus rhythm with AV Wenckebach — as in Figure-4 in this post ).

Defibrillator 73

Defibrillator ALS Coronary OR 73

EMDocs

FEBRUARY 7, 2024

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. 2023 observational study found increased risk of pancreatitis (adjusted HR of 9.09, 95% CI 1.25-66). 2023 Oct 5:e2319574.

Allergic Reaction 75

Allergic Reaction ALS CAD OR 75

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. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.

EMS 74

EMS ALS OR ACS 74

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 - ).

EMS 100

EMS CPR ED Coronary 100

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

Coronary 110

Coronary ACS OR EMR 110

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. Immediate and early percutaneous coronary intervention in very high-risk and high-risk non-ST segment elevation myocardial infarction patients. 2009;95:1701–1706. As per Drs.

ACS 85

ACS Coronary ALS CAD 85

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 72

STEMI Coronary OR ALS 72

Dr. Smith's ECG Blog

JANUARY 9, 2023

Repeat CT angio chest (not CT coronary, unclear what protocol) showed possible LAD aneurysm and thrombus. Finally, coronary angiography was performed (at least 5 days after presentation) which confirmed LAD aneurysm with large thrombus burden, TIMI 0 flow, thrombectomy performed. A missed OMI like this can be devastating. =

Coronary 52

Coronary STEMI Heart Attack OR 52

Dr. Smith's ECG Blog

JULY 31, 2020

Their OMI Manifesto details how use of standard STEMI criteria results in an unacceptable level of inaccuracy, in which an estimated 25-30% of acute coronary occlusions are missed! The article by Aslanger, Smith et al that is featured above in today’s post has just been published.

STEMI 52

STEMI Coronary EMR ALS 52

ACEP Now

MARCH 14, 2024

2023 Jul 17. Treasure Island (FL): StatPearls Publishing; 2023 Jan– PMID: 28846317. Tintinalli JE, Stapczynski J, Ma O, et al. Accessed October 21, 2023. Acute myocardial infarction with normal and near normal coronary arteries. Arnoldo BD, Purdue GF, Kowalske K, et al. In: StatPearls [Internet].

Operating Room 52

Operating Room ACS Critical Care Coronary 52

Dr. Smith's ECG Blog

JANUARY 27, 2024

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 the patient had a transient acute coronary occlusion that spontaneously reperfused but is at risk for reocclusion. Deutch et al.

STEMI 96

STEMI Coronary ACS ED 96

Dr. Smith's ECG Blog

FEBRUARY 10, 2023

Inferior ST Depression does NOT mean there is inferior subendocardial ischemia; it is generally reciprocal to high lateral (aVL) subepicardial ischemia (OMI/STEMI) == MY Comment by K EN G RAUER, MD ( 2/10/2023 ): == There are certain patterns in ECG interpretation that experienced providers are able to immediately recognize. See text ).

STEMI 52

STEMI ALS Coronary OR 52

Dr. Smith's ECG Blog

JULY 27, 2023

I was not worried for a coronary etiology. PEARL #3: The pathophysiologic mechanism for producing amphetamine-induced acute MI is unclear ( Bazmi et al — SQUMJ 17(10); e31-37, 2017 — and — Sinha et al — Case Rep Cardiol, 2016 ). The precordial findings are typical for a young AA male See 20 similar cases here.

Coronary 52

Coronary ACS Naloxone Plasma 52

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 116

STEMI Emergency Department Coronary OR 116

Dr. Smith's ECG Blog

JANUARY 1, 2024

His medical history includes hypertension, a decade-long battle with diabetes, ischemic heart disease, a coronary bypass graft surgery ten years ago, a diagnosis of congestive heart failure for the last five years, and a prior ICD implantation five years ago.

Coronary 91

Coronary EMR STEMI Emergency Department 91

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

MAY 23, 2023

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. Of the Non-STEMI in our cohort, about 25% will actually have acute coronary occlusion. So this study is worthless and must be ignored.

STEMI 82

STEMI Coronary Paramedic OR 82

Dr. Smith's ECG Blog

MAY 8, 2023

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. Electrocardiographic Diagnosis of Acute Coronary Occlusion Myocardial Infarction in Ventricular Paced Rhythm Using the Modified Sgarbossa Criteria.

STEMI 52

STEMI Coronary ED ACS 52

Dr. Smith's ECG Blog

SEPTEMBER 16, 2024

A coronary angiogram was done that did not show significant coronary artery disease. I have periodically called attention to examples of the Ashman phenomenon as they occur in Dr. Smith's ECG Blog ( See My Comments in the January 5, 2020 post — the June 17, 2020 post — and the March 30, 2023 post , among others ).

Defibrillator 70

Defibrillator Coronary OR ALS 70

Core EM

JULY 23, 2024

High risk and low prevalence diseases: Blast injuries American Journal of Emergency Medicine, 2023 Background Blast injuries stem from the instantaneous transformation of a substance from solid or liquid to gas, releasing energy in the form of heat, light, pressure, and sound. Read More Citation: Bukowski J., Nowadly C.D., Schauer S.G.,

EMS 100

EMS Emergency Medical Services OR Coronary 100

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 97

STEMI Coronary OR ALS 97

Dr. Smith's ECG Blog

NOVEMBER 5, 2023

By Magnus Nossen, edits by Grauer and Smith The patient is a 70-something female with DMII, HTN and an extensive prior history of coronary artery disease and myocardial infarctions. PLUS — Today's patient is an older woman with known severe coronary disease who presented with new chest pain. She's had multiple PCI procedures.

Coronary 94

Coronary OR ALS 94

Core EM

MARCH 7, 2024

High risk and low prevalence diseases: Blast injuries American Journal of Emergency Medicine, 2023 Background Blast injuries stem from the instantaneous transformation of a substance from solid or liquid to gas, releasing energy in the form of heat, light, pressure, and sound. Read More Citation: Bukowski J., Nowadly C.D., Schauer S.G.,

EMS 100

EMS Emergency Medical Services OR Coronary 100

Dr. Smith's ECG Blog

OCTOBER 6, 2023

Unfortunately, and predictably, he now has rather severe heart failure. == MY Comment , by K EN G RAUER, MD ( 10/6 /2023 ): == We’ve reviewed multiple variations on the “ theme ” of deWinter T waves in Dr. Smith’s ECG Blog ( See My Comment at the bottom of the page in the April 17, 2023 post — to name just one ).

ALS 68

ALS Coronary OR 68

Dr. Smith's ECG Blog

JANUARY 5, 2024

Heitner et al. 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 PDA plaque was also bulky, but was not described as inflamed or ulcerated. DOI:10.1161/CIRCINTERVENTIONS.118.007305), DOI:10.1161/CIRCINTERVENTIONS.118.007305),

ACS 101

ACS ALS OR STEMI 101

Dr. Smith's ECG Blog

MAY 31, 2023

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. Meine TJ, Roe M, Chen A, Patel M, Washam J, Ohman E, Peacock W, Pollack C, Gibler W, Peterson E. Am Heart J. 2005;149:1043–1049.

STEMI 73

STEMI Coronary ACS OR 73

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 2023 Jul 17]. Accessed 22 June 2024.

OR 88

OR Coronary ALS 88

Dr. Smith's ECG Blog

APRIL 17, 2023

CASE #1: We have presented many examples of LVH that masquerades as an OMI "mimic" ( See My Comment in the April 2, 2023 post — and the April 14, 202 3 post , to name just the most recent examples ). For review — I've copied below my summary of this entity from My Comment in the February 10, 2023 post of Dr. Smith's ECG Blog.

OR 52

OR STEMI ACS Emergency Department 52