EMOttawa

DECEMBER 18, 2023

2023 Oct 1;8(10):946-956 Question: Does the modified GRACE score incorporating continuous troponin improve ACS risk prediction? The post Modification of the GRACE Risk Score for Risk Prediction in Patients With Acute Coronary Syndromes appeared first on EMOttawa Blog. Methodology: 3/5 Usefulness: 1/5 Georgiopoulos G, et al.

Coronary 52

Coronary ACS ALS 52

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

CanadiEM

NOVEMBER 7, 2023

For the October 2023 issue of CJEM, we collaborated with their team to present “Machine learning for the diagnosis of acute coronary syndrome using a 12-lead ECG: a systematic review”​1​​ in a visually simplified format. We often rely on our clinicians interpretation of the 12-lead, instead.

Coronary 52

Coronary OR 52

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 107

Coronary ACS ALS OR 107

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

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 75

Coronary ED OR 75

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

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

Dr. Smith's ECG Blog

OCTOBER 20, 2024

The ST segment changes are compatible with severe subendocardial ischemia which can be caused by type I MI from ACS or potentially from type II MI (non-obstructive coronary artery disease with supply/demand mismatch). This patient is actively dying from a left main coronary artery OMI and cardiac arrest from VT/VF or PEA is imminent!

Coronary 125

Coronary ACS Emergency Department Defibrillator 125

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 76

Coronary STEMI ED OR 76

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 93

Naloxone OR Overdose BLS 93

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 110

Defibrillator Coronary Epinephrine ACS 110

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

Dr. Smith's ECG Blog

NOVEMBER 14, 2024

The patient is a 54yo man with diabetes and a known history of coronary diseae ( prior stent placement ) — who presented with new CP ( C hest P ain ) — therefore very high likelihood for having an acute coronary event. In the setting of acute inferior OMI — seeing ST elevation in lead V1 suggests associated RV MI.

ED 116

ED Coronary Paramedic OR 116

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-9-1-1 121

E-9-1-1 ACS Coronary STEMI 121

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 118

STEMI Coronary ALS CAD 118

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 137

Life Support Coronary CPR ICU 137

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

ACEP Now

APRIL 4, 2024

This patient had known coronary artery disease (CAD), and previously required drug eluting stents to the obtuse marginal and diagonal arteries. 1 Despite the rarity of dextrocardia, coronary artery disease can occur with a similar frequency to that of the general population. Coronary heart disease in situs inversus totalis.

Coronary 40

Coronary STEMI CAD Emergency Department 40

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 108

Coronary STEMI Emergency Department OR 108

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 91

Coronary CAD ACS OR 91

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-9-1-1 119

E-9-1-1 Coronary ACS BLS 119

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 129

STEMI Coronary 129

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 63

Coronary OR 63

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

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

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-9-1-1 111

E-9-1-1 Coronary ALS ED 111

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 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-9-1-1 110

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

Coronary 136

Coronary OR EMS ED 136

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 105

Coronary OR 105

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 138

STEMI Allergic Reaction Coronary Ambulance 138

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 71

Coronary STEMI EMS OR 71

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 77

Defibrillator ALS Coronary OR 77