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-9-1-1 128

E-9-1-1 Coronary STEMI ALS 128

Dr. Smith's ECG Blog

SEPTEMBER 29, 2024

In other words: 1) infarct of the LAD territory (much of which could be old) and 2) inferior-posterior-lateral infarct. == MY Comment , by K EN G RAUER, MD ( 9/27 /2024 ): == I found today's case insightful for a number of reasons. See Discussion in the June 29, 2024 post of Dr. Smith' ECG Blog ).

STEMI 110

STEMI Coronary Defibrillator OR 110

EMDocs

FEBRUARY 24, 2024

2024 Jan;75:137-142. 2024 Jan;22(1):140-151. 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 98

Coronary STEMI ED OR 98

Dr. Smith's ECG Blog

MAY 27, 2024

1] But there are multiple other abnormalities that make this ECG diagnostic of Occlusion MI, localized likely to the right coronary artery: 1. Systematic review and meta-analysis of diagnostic test accuracy of ST-segment elevation for acute coronary occlusion. Int J Cardiol 2024 2. Eur Herat J Digital Health 2024

STEMI 123

STEMI Coronary ALS Emergency Department 123

Dr. Smith's ECG Blog

MARCH 10, 2025

But like many similar studies, the study was small (one year at one centre with no indication of the incidence of acute coronary occlusion), and it used as the gold standard the final cardiologist interpretation of the ECG - not the patient outcome! West J Emerg Med [Internet] 2024 [cited 2024 Aug 26];25(1):38.

STEMI 89

STEMI OR Coronary Emergency Department 89

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 108

Coronary CAD ACS OR 108

Dr. Smith's ECG Blog

OCTOBER 3, 2024

Coronaries were clean. Click here to sign up for Queen of Hearts Access == MY Comment , by K EN G RAUER, MD ( 10/1 /2024 ): == I looked at the ECG in today’s case knowing only that the patient was a younger male adult with CP ( C hest P ain ). Sam : "Yes, this case was sent to me. It was a man in his 30s with chest pain. 27 post ).

E-9-1-1 124

E-9-1-1 Coronary ALS ED 124

Dr. Smith's ECG Blog

JUNE 23, 2024

The patient was treated as possible NSTEMI and underwent coronary angiography about 4 hours after presentation. TIMI 3 means the rate of passage of dye through the coronary artery is normal by angiography.) Initial hsTnI was 384 ng/L. The report describes a 60% proximal LAD lesion with TIMI 3 flow.

Coronary 118

Coronary CAD CPR ICU 118

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. Accessed May 28, 2024.

E-9-1-1 139

E-9-1-1 ACS Emergency Department Coronary 139

Dr. Smith's ECG Blog

APRIL 22, 2024

A comparison of electrocardiographic changes during reperfusion of acute myocardial infarction by thrombolysis or percutaneous transluminal coronary angioplasty. Total coronary occlusion, if very brief, may have minimal infarction and yet be very dangerous. Am Heart J. 2000;139:430–436.

Coronary 118

Coronary STEMI ED OR 118

The Bottom Line

OCTOBER 13, 2024

JAMA 2024; 332:979 – 988. 2024.17888 Clinical Question In adult patients undergoing coronary artery bypass surgery (CABG) is supplementing potassium when serum concentration is ≤ 3.5 Potassium Supplementation and Prevention of Atrial Fibrillation After Cardiac Surgery: The TIGHT K Randomized Clinical Trial O’Brien.

Coronary 68

Coronary 68

Dr. Smith's ECG Blog

JUNE 27, 2024

The proof of this is that only 5% of patients enrolled had acute coronary occlusion. Coronary Angiography after Cardiac Arrest without ST-Segment Elevation. A reliable study would keep track of all patients with shockable arrest and analyze the ones who were not enrolled to see their outcomes. This study failed to do so. 5% vs. 58%!!

Defibrillator 113

Defibrillator STEMI Coronary ALS 113

Dr. Smith's ECG Blog

JUNE 7, 2024

The most likely would be #2) initially normal, then #3) subtle OMI, then #4) obvious STEMI, and then #1) reperfusion: In other words, the patient with an initially normal ECG develops an acute coronary occlusion, with ECGs that progress from subtle to obvious, and then reperfuse after angiography. But that’s not always the case.

STEMI 112

STEMI Coronary OR EMS 112

Dr. Smith's ECG Blog

OCTOBER 12, 2024

Preliminary findings documented in the cath lab were “Anterior STEMI and no significant coronary artery disease.” (!!!) A new 4-variable formula to differentiate normal variant ST segment elevation in V2-V4 (early repolarization) from subtle left anterior descending coronary occlusion - Adding QRS amplitude of V2 improves the model.

STEMI 116

STEMI Coronary Emergency Department ACS 116

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 120

Coronary STEMI Emergency Department OR 120

Dr. Smith's ECG Blog

OCTOBER 15, 2024

Additionally, his cardiac telemetry monitor showed runs of accelerated idioventricular rhythm, a benign arrhythmia often associated with coronary reperfusion. The patient is a 75-year old man with known coronary disease, including prior LAD and LCx OMI. That this patient has severe underlying coronary disease is indisputable.

OR 116

OR STEMI Coronary ED 116

Dr. Smith's ECG Blog

MAY 13, 2024

Dr. Smith and other authors showed the utility of Speckle Tracking Strain Echo in this case report: Diagnosis of acute coronary occlusion in patients with non–STEMI by point-of-care echocardiography with speckle tracking Repeat ECG: Slightly less hyperacute T waves, likely indicating improving flow compared to the first ECG.

OR 120

OR STEMI Heart Attack Coronary 120

Dr. Smith's ECG Blog

AUGUST 11, 2024

Despite many ECG signs of OMI being missed the door-to-cath time was still fast, because all the healthcare providers were focused on the pathology of acute coronary occlusion and not were distracted by the lack of STEMI criteria. Start using the terms acute coronary occlusion and occlusion MI.

STEMI 100

STEMI Paramedic Coronary EMS 100

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 native QRS may be more obvious in one lead or another. == MY Comment , by K EN G RAUER, MD ( 5/30 /2024 ): == I was not taught about artifact in medical school. Take advantage of all the telemetry leads.

Defibrillator 81

Defibrillator ALS Coronary OR 81

EMDocs

SEPTEMBER 7, 2024

A 70-year-old female with a past medical history of hypertension, coronary artery disease s/p 2x drug eluting stent placement one month ago, atrial fibrillation on apixaban presents to the ED with weakness and lightheadedness. Updated 2024 Jan 9]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. J Emerg Med. 2011.06.006.

EMS 97

EMS E-9-1-1 Operating Room OR 97

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. West J Emerg Med 2024).

STEMI 117

STEMI Coronary ACS ED 117

Dr. Smith's ECG Blog

JULY 21, 2024

It shows a proximal LAD occlusion, in conjunction with a subtotally occluded LMCA ( Left Main Coronary Artery ). Upon contrast injection of the LMCA, the patient deteriorated, as the LMCA was severely diseased and flow to all coronary arteries ( LAD, LCx and RCA ) was compromised. He was taken immediately to the cath lab.

Defibrillator 131

Defibrillator Coronary ALS STEMI 131

Dr. Smith's ECG Blog

JULY 11, 2024

The scan did not find PE, but showed evidence of coronary plaque: There are areas of dense white in the LAD (red and blue circles) and in the first diagonal (green circle). This is an RAO cranial projection of the left coronary vessels after thrombectomy and stenting. A chest x-ray in the ED found bilateral pleural effusions.

Coronary 113

Coronary ED ACS OR 113

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. High Elevation Travel & Altitude Illness | CDC Yellow Book 2024.” Accessed 22 June 2024.

OR 97

OR Coronary ALS 97

Dr. Smith's ECG Blog

JANUARY 9, 2024

*Temporarily decreasing the LRL of the ICD/Pacemaker can promote intrinsic depolarization which is beneficial when assessing ST segments and T waves for ischemia. == MY Comment , by K EN G RAUER, MD ( 1/10 /2024 ): == Highly insightful post by Dr. Magnus Nossen — that brings home a number of very important points.

Coronary 119

Coronary ACS ED OR 119

Dr. Smith's ECG Blog

AUGUST 6, 2024

All coronary arteries were patent without atherosclerotic change. Dr. Myocarditis can be very difficult to separate from OMI on ECG, and often some form of coronary artery imaging will need to be done to rule out OMI. The ECG shows slight ST Elevation in an inferolateral distribution. Notice how QOH is not fooled by this ST-Elevation.

Coronary 104

Coronary OR STEMI EMS 104

Dr. Smith's ECG Blog

SEPTEMBER 11, 2024

Click here to sign up for Queen of Hearts Access == MY Comment , by K EN G RAUER, MD ( 9/11 /2024 ): == Among the important concepts brought out by today's case are the following: #1) — Is acute OMI a common cause of syncope ? #2) Former resident: "The biggest piece for me was the size of the T waves in relation to everything else.

EMS 114

EMS CPR ED Coronary 114

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

JUNE 11, 2024

Acad Emerg Med 2024;31:296-300 == MY Comment , by K EN G RAUER, MD ( 6/6 /2024 ): == Recognition of repolarization variants can be challenging. It is clearly missed by the conventional algorithm. Emergency department Code STEMI patients with initial electrocardiogram labeled ‘normal’ by computer interpretation: a 7-year retrospective review.

STEMI 113

STEMI Coronary Emergency Department OR 113

Dr. Smith's ECG Blog

AUGUST 9, 2024

Serial ECGs enhance the diagnosis of acute coronary syndrome. Association of intravenous morphine use and outcomes in acute coronary syndromes: Results from the Crusade Quality Improvement Initiative. If the story and ECG findings are concerning, use your clinical judgment to advocate for PCI. Washam, J. Peacock, W. Pollack, C.

STEMI 107

STEMI Coronary Heart Attack ACS 107

Dr. Smith's ECG Blog

OCTOBER 22, 2024

The coronary angiography showed a 100% ostial main (obtuse) marginal occlusion!" Dominant right coronary, atherosclerotic and calcified. Presence of a single coronary lesion: occlusion of the ostial main marginal.

Coronary 66

Coronary STEMI OR ALS 66

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. The Queen of Hearts AI app will hopefully be FDA approved in Q1 of 2024. She's had multiple PCI procedures. It is already approved in Europe.

Coronary 111

Coronary OR ALS 111

Dr. Smith's ECG Blog

OCTOBER 6, 2024

Click here to sign up for Queen of Hearts Access == == MY Comment , by K EN G RAUER, MD ( 10/6 /2024 ): == Today's case provides an excellent example of how prompt recognition of acute OMI worked as it should to expedite cardiac cath and coronary reperfusion. It had never been described before.

STEMI 77

STEMI Coronary ED 77

Dr. Smith's ECG Blog

OCTOBER 8, 2024

Available from: [link] Click here to sign up for Queen of Hearts Access == MY Comment , by K EN G RAUER, MD ( 10/8 /2024 ): == It’s always easier to look back at a case from the comfort of one’s home — and to criticize decisions that were made. High T waves in the earliest stage of myocardial infarction. Am Heart J [Internet].

OR 123

OR STEMI ICU Coronary 123

EMDocs

MARCH 25, 2024

Video 3: Coronary approach to the gallbladder POCUS Findings Sonographically, the gallbladder is situated in the right upper quadrant as an elongated pear-shaped organ on the inferior surface of the liver. Treasure Island (FL): StatPearls PublishingCopyright © 2024, StatPearls Publishing LLC.; J Educ Teach Emerg Med. 2021;6:V25-v29.

ALS 98

ALS Coronary Emergency Department ED 98

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. The Queen of Hearts AI app will hopefully be FDA approved in Q1 of 2024. that is, show a pattern of labile ST-T wave changes not due to an acute coronary event.

E-9-1-1 116

E-9-1-1 Coronary EMS ED 116

Dr. Smith's ECG Blog

JULY 24, 2024

Easy LINK — [link] — My New E CG P odcasts ( 5/28/2024 ): These podcasts are part of the Mayo Clinic Cardiovascular CME Podcasts Series ( "Making Waves" ) — hosted by Dr. Anthony Kashou. 2:25 — Dr. Grauer: The 1st Error : Too many clinicians in 2024 are still stuck in the outdated millimeter-based STEMI Paradigm”.

E-9-1-1 52

E-9-1-1 Coronary STEMI OR 52