EMergucate

JANUARY 30, 2023

The following ECG was obtained from a 74 year old man with a history of coronary artery bypass grafting and aortic valve replacement who presented to hospital complaining of 4 days of palpitations …

Coronary 100

Coronary EMS 100

Dr. Smith's ECG Blog

JUNE 5, 2024

Why Was Cardiac Cath Negative for Coronary Disease? As noted by Dr. Nossen — this patient qualified as MINOCA ( M yocardial I nfarction with N on- O bstructive C oronary A rteries ) — since troponin was positive on his 2nd admission, yet there was no evidence of obstructive coronary disease on cath.

Coronary 101

Coronary ACS ALS OR 101

Core EM

JULY 23, 2024

Isolated posterior MI is less common (3-8% of OMI) and presents with isolated ST-depressions in the anterior precordial leads (V1-V4), representing reciprocal changes to posterior left ventricular wall myocardial infarction as a result of distal occlusion of either the left circumflex or right coronary artery. 2023, June 8).

STEMI 173

STEMI Coronary Emergency Department OR 173

ALiEM

SEPTEMBER 16, 2024

A 94-year-old female with a past medical history of hypertension, coronary artery disease, chronic venous stasis, and permanent pacemaker placement initially presented to triage complaining of left hip pain in the setting of a fall shortly prior to arrival. 2023 May 6;15:1-13. References Levy D, Goyal A, Grigorova Y, Farci F, Le JK.

ACS 152

ACS Coronary OR 152

Core EM

NOVEMBER 15, 2023

The Case A 62-year-old male with a history of Hypertension, Hyperlipidemia, Coronary Artery Disease with stents, Pulmonary Embolism on Eliquis, presents with sudden onset, severe, mid-sternal chest pain that started 15 minutes prior to arrival. Discussion Case Discussion: The patient’s history was concerning for an acute coronary syndrome.

Coronary 130

Coronary STEMI ED 130

Dr. Smith's ECG Blog

JANUARY 25, 2024

A 40-something with severe diabetes on dialysis and with known coronary disease presented with acute crushing chest pain. As per Dr. Smith — today's patient is a 40-something year old patient with severe diabetes, renal failure and known coronary disease — who presents with “acute crushing CP”. Here is his ED ECG: What do you think?

Coronary 78

Coronary ED OR 78

Core EM

FEBRUARY 23, 2024

Isolated posterior MI is less common (3-8% of OMI) and presents with isolated ST-depressions in the anterior precordial leads (V1-V4), representing reciprocal changes to posterior left ventricular wall myocardial infarction as a result of distal occlusion of either the left circumflex or right coronary artery. 2023, June 8).

STEMI 130

STEMI Coronary Emergency Department OR 130

EMDocs

FEBRUARY 24, 2024

Epub 2023 Nov 3. #2: Epub 2023 Oct 4. #3: 3: New AI-Powered OMI Detector Spoon Feed An artificial intelligence (AI) ECG model outperformed standard STEMI criteria in identifying occlusion myocardial infarction (OMI) confirmed by coronary angiography. Source High risk and low prevalence diseases: Infected urolithiasis.

Coronary 77

Coronary STEMI ED OR 77

EMDocs

NOVEMBER 6, 2023

Author: Brit Long, MD (@long_brit) // Reviewed by Alex Koyfman, MD (@EMHighAK) The American Heart Association 2023 Guideline for managing cardiac arrest or life-threatening toxicity due to poisoning was recently released. Vasodilators, such as phentolamine and/or nitrates, are reasonable for coronary vasospasm from sympathomimetic poisoning.

Naloxone 94

Naloxone OR Overdose BLS 94

Dr. Smith's ECG Blog

JULY 25, 2024

But cardiac arrest is a period of near zero flow in the coronary arteries and causes SEVERE ischemia. Smith's ECG Blog ( See My Comment in the March 1, 2023 post) — DSI does not indicate acute coronary occlusion! It also does not uniformly indicate severe coronary disease. And what do you want to do?

Defibrillator 105

Defibrillator Coronary Epinephrine ACS 105

ALiEM

FEBRUARY 16, 2024

An 86-year-old man with a past medical history of coronary artery disease, hypertension, hyperlipidemia, chronic kidney disease, COPD, choledocholithiasis requiring ERCP and sphincterotomy 2 years ago presented with five days of feeling unwell. History was limited due to cognitive impairment. Khandelwal, N. and Suri, S.

Coronary 161

Coronary OR 161

REBEL EM

JUNE 1, 2023

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. Resus 2023. Advanced imaging post-arrest is a possible modality to achieve this end. Article: Branch KHR et al.

Coronary 145

Coronary Defibrillator CPR ALS 145

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

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

EMDocs

OCTOBER 28, 2023

2023 Sep;164(3):667-669. Epub 2023 Apr 20. #2: Source STREAM-2: Half-Dose Tenecteplase or Primary Percutaneous Coronary Intervention in Older Patients With ST-Segment-Elevation Myocardial Infarction: A Randomized, Open-Label Trial. 2023 Aug 29;148(9):753-764. Epub 2023 Jul 13. #3: 2023 Sep 1;95(3):432-441.

STEMI 66

STEMI Emergency Department Coronary OR 66

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. Indian J Endocrinol Metab. 2012 Jul;16(4):614-20. doi: 10.4103/2230-8210.98023. PMID: 22837927; PMCID: PMC3401767.

Plasma 161

Plasma Coronary Emergency Department OR 161

REBEL EM

SEPTEMBER 14, 2023

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. Zeymer HT et al. Extracorporeal Life Support in Infarct-Related Cardiogenic Shock. Control: 53.4% D ECLS: 18.2% Control 8.7% Control 38.0%

Life Support 136

Life Support Coronary CPR ICU 136

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

A 56 year old male with a history of diabetes, dyslipidemia, hypertension, and coronary artery disease presented to the emergency department with sudden onset weakness, fatigue, lethargy, and confusion. For more on use of Opiates with acute ischemic CP — See the January 6, 2023 post in Dr. Smith's ECG Blog ).

Coronary 102

Coronary STEMI Emergency Department OR 102

Dr. Smith's ECG Blog

OCTOBER 3, 2024

Coronaries were clean. While statistical likelihood of acute OMI is clearly lower in younger adults — nothing is ruled out by age alone ( as per My Comment in the January 9, 2023 and December 5, 2023 posts in Dr. Smith's ECG Blog ). Sam : "Yes, this case was sent to me. It was a man in his 30s with chest pain.

E-9-1-1 105

E-9-1-1 Coronary ALS ED 105

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

APRIL 9, 2024

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. Each main coronary artery (LAD, RCA and LCx) are shown in separate images.

Coronary 85

Coronary CAD ACS OR 85

EMDocs

AUGUST 5, 2023

2023 Jul;188:109785. Epub 2023 Apr 3. #2: 2023 May 1;6(5):e2311455. 3: Recalibrating…HEART Score with High-Sensitivity Troponin T Spoon Feed A recalibrated HEART score ≤ 3 utilizing hs-cTnT ruled out MACE (adjudicated type 1 MI, unplanned coronary revascularization, and all cause death) at 30 days at a sensitivity of 98.5%

Coronary 64

Coronary OR 64

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

OCTOBER 26, 2023

Artificial Intelligence-Augmented ECG Interpretation Using Smartphone Technology @TheEKGGuy [link] == MY Comment , by K EN G RAUER, MD ( 10/26 /2023 ): == Our THANKS to Drs. @RobertHermanMD on Making Waves from Mayo clinic. I’ll offer a word of caution — and a word on the prospects for continued future development.

Coronary 52

Coronary STEMI OR 52

Dr. Smith's ECG Blog

SEPTEMBER 15, 2023

Here it is: So we looked for the followup: Cath lab was activated per protocol and coronary angiogram found no angiographic significant obstructive disease in the LAD, LCX, and RCA. 17, 2023 post — allows you within seconds to recognize with certainty that the unusual deflections in the ECG in front of you is the result of APTA.

STEMI 124

STEMI Coronary 124

EMDocs

SEPTEMBER 15, 2023

ST segment elevation, or even an isoelectric ST segment, in these leads is abnormal and should make us concerned for ischemia Source Acute Coronary Occlusion in a Patient With Prior Known Right Bundle Branch Block: Another Chink in the Armor for the ST-Elevation Myocardial Infarction Criteria. 2023 Aug;82(2):219-221. Epub 2023 May 16.

Emergency Medical Services 61

Emergency Medical Services Coronary Emergency Department EMS 61

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? How Can We Prove that ECG #1 is VT?

Coronary 132

Coronary OR EMS ED 132

REBEL EM

SEPTEMBER 28, 2023

STREAM-2: Half-Dose Tenecteplase or Primary Percutaneous Coronary Intervention in Older Patients With ST-Segment-Elevation Myocardial Infarction: A Randomized, Open-Label Trial. Based on this, the authors did a literature review and found that there is an increasing rate of ICH and major non-intracranial bleeding starting at ≈60 years of age.

STEMI 137

STEMI Allergic Reaction Coronary Ambulance 137

Dr. Smith's ECG Blog

DECEMBER 7, 2023

I quickly reviewed the patient’s records and saw that she was a 53 year old woman with a history of BMI 40, but no other identifiable risk factors for coronary artery disease. In this patient with stuttering symptoms and rising troponin, there is no other option but to perform emergent coronary angiography. Hers is shown below.

Coronary 101

Coronary OR 101

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

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. Accessed November 29, 2023. Coronary thrombosis in acute pancreatitis. Intern Med.

STEMI 52

STEMI Coronary ACS Critical Care 52

Dr. Smith's ECG Blog

NOVEMBER 27, 2023

But do they represent acute coronary occlusion? But coronaries were normal, and serial high sensitivity troponin was undetectable. Based on ECG changes and echo findings, the patient was diagnosed as coronary vasospasm. Formal echo showed EF 55% with mild inferolateral hypokinesis without any prior for comparison.

STEMI 85

STEMI Coronary OR ED 85

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

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.

E-9-1-1 134

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

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

MARCH 1, 2023

It is unclear to me whether this case could represent 1) simple supply/demand mismatch due to increased demand from epinephrine, 2) Kounis syndrome (usually described as mast cell mediated coronary vasospasm during allergic reaction), 3) brief autolysed left main or LAD ACS with no findings on later echo and CT coronary angio, or 4) something else.

Allergic Reaction 52

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

Dr. Smith's ECG Blog

AUGUST 6, 2023

link] == MY Comment, by K EN G RAUER, MD ( 8/6 /2023 ): == Brilliant talk by Dr. Smith on the state of the art addressing the “need for OMI — and the fallacy of STEMI”. Doing so allows you to put YOURSELF to the TEST ( keeping in mind that all ECGs shown are from patients with chest pain suggestive of potential acute coronary disease ).

OR 90

OR STEMI Coronary 90