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

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 1, 2023

See the full post here == MY Comment , by K EN G RAUER, MD ( 10/1 /2023 ): == It is often insightful to "look back" — and see from where we have come, which Dr. Meyers skillfully does with today's repost from October 5, 2021. This patient in today's case was a man in his 60s with a known history of coronary disease, including prior stents.

OR 124

OR STEMI Coronary CAD 124

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. It takes time for that ischemia to resolve.

Defibrillator 105

Defibrillator Coronary Epinephrine ACS 105

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

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. He denied changes to urination or bowel movements.

Coronary 161

Coronary OR 161

Dr. Smith's ECG Blog

SEPTEMBER 22, 2023

This is diagnostic of full reperfusion.] An old ECG was found: As you can see, this patient has zero baseline STE, and normal T-waves. You never know if a patient's baseline has normal large STE or complete absence of STE, or somewhere in between. 90% of normals have some STE in V2 and V3. I focus my comment on this initial ECG in today's case.

OR 118

OR STEMI Coronary 118

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

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. It’s time to learn smarter. Am J Emerg Med. 2024 Jan;75:137-142. 2023.10.049.

Coronary 77

Coronary STEMI ED OR 77

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. So I would be worried about inferior OMI. At midnight.

E-9-1-1 119

E-9-1-1 ACS Coronary STEMI 119

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

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

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 114

STEMI Coronary ALS CAD 114

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 110

OR STEMI EMS ED 110

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

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 ). This was sent to me from Sam Ghali ( @EM_Resus ) with no other information. Real or just fake?"

E-9-1-1 105

E-9-1-1 Coronary ALS ED 105

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

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. This is another case sent by the undergraduate (who is applying to med school) who works as an EKG tech. No ECG was ordered on Day #1.

Coronary 102

Coronary STEMI Emergency Department OR 102

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.

E-9-1-1 113

E-9-1-1 Coronary ACS BLS 113

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

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

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

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 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. Thus, the lumen observed may actually still be the same size as the original, normal lumen. Unfortunately, vascular remodeling is variable and inconsistent.

Coronary 110

Coronary ACS OR EMR 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 132

Coronary OR EMS ED 132

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 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

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

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. Am J Emerg Med 2023 2.

STEMI 72

STEMI Coronary OR ALS 72

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

Don't Forget the Bubbles

OCTOBER 7, 2024

However, vertical flow can result in myocardial injury secondary to coronary artery spasm. Electrical injuries can range from something minor that needs no medical input to tetany of respiratory muscles through to cardiac arrest secondary to dysrhythmia (VF, VT or asystole). Was the voltage high or low (as below)?

ACS 80

ACS Life Support OR CPR 80

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. Stein et al.

E-9-1-1 134

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

Dr. Smith's ECG Blog

SEPTEMBER 8, 2023

In the context of remote rural communities, this can help emergency physicians advocate for their patients, and reduce reperfusion delays by days for STEMI(-)OMI == MY Comment , by K EN G RAUER, MD ( 9/8 /2023 ): == Today’s case is distinguished by its occurrence in a remote rural community ( where the nearest cath lab is a plane ride away ).

OR 124

OR STEMI Coronary Emergency Department 124

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. The Case FIGURE 1: Initial EKG were notable for a leukocytosis of 23.19 Click to enlarge.)

STEMI 52

STEMI Coronary ACS Critical Care 52

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. That is what Emergency Medicine is all about. == MY Comment , by K EN G RAUER, MD ( 9/3 /2023 ): == I’ve seen a “common theme” with many of the ECGs that Drs.

Defibrillator 126

Defibrillator Coronary STEMI CPR 126

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. No similar symptoms in the past. Pericarditis?

Coronary 52

Coronary STEMI Heart Attack OR 52