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 76

Coronary STEMI ED OR 76

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 80

STEMI Coronary Defibrillator OR 80

Dr. Smith's ECG Blog

NOVEMBER 14, 2024

Apparently the intern also recognized it (he is an avid reader of the blog), but the staff overruled him." = My Comment , by K EN G RAUER, MD ( 11/14 /2024 ): = I share Dr. Smith's disappointment with regard to the failure to recognize the obvious acute OMI evident on today's initial ECG ( that I've reproduced and labeled in Figure-1 ).

ED 116

ED Coronary Paramedic OR 116

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

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. Int J Cardiol 2024 3. But does this matter?

STEMI 118

STEMI Coronary ALS CAD 118

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-9-1-1 111

E-9-1-1 Coronary ALS ED 111

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 119

STEMI Coronary ALS Emergency Department 119

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

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 108

Coronary CAD CPR Critical Care 108

Dr. Smith's ECG Blog

OCTOBER 27, 2024

Initial 4th generation troponin I was 10 ng/mL is consistent with large MI due to acute coronary occlusion (OMI). There are moderate coronary artery calcifications. Immediate and early percutaneous coronary intervention in very high-risk and high-risk non-ST segment elevation myocardial infarction patients.

STEMI 116

STEMI ED Coronary EMS 116

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

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 106

OR STEMI Coronary ED 106

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 98

STEMI Coronary Emergency Department OR 98

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 77

Defibrillator ALS Coronary OR 77

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 117

Coronary STEMI ED OR 117

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 108

Coronary STEMI Emergency Department OR 108

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-9-1-1 137

E-9-1-1 ACS Emergency Department Coronary 137

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

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 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 97

STEMI Coronary OR EMS 97

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 91

Defibrillator STEMI Coronary ALS 91

Dr. Smith's ECG Blog

NOVEMBER 8, 2024

He remained chest pain free and underwent coronary angiography the following day. Sometimes a poor quality tracing is all you have to make your decision. == MY Comment , by K EN G RAUER, MD ( 11/6 /2024 ): == Today’s case by Dr. Nossen brings out a series of important points: As per comments by Drs. scratching? ) in the LA electrode.

ACS 79

ACS Coronary STEMI OR 79

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 31, 2024

Learn to read the ECG for sublte OMI, and get the Queen of Hearts. == MY Comment , by K EN G RAUER, MD ( 11/1 /2024 ): == The beauty of today's case is its simple efficiency. Perhaps the highly unusual initial rhythm in today's case was simply the result of SA nodal ischemia that resolved following coronary reperfusion.

STEMI 104

STEMI Coronary 104

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 74

EMS E-9-1-1 Operating Room OR 74

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 74

STEMI Paramedic Coronary EMS 74

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 108

OR STEMI Heart Attack Coronary 108

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 86

OR Coronary ALS 86

Dr. Smith's ECG Blog

NOVEMBER 19, 2024

Learning Points: 1) Learn to recognize Subtle OMI 2) Before assuming an OMI is reperfused, verify it by obtaining more ECGs to see evolution of reperfusion. == MY Comment , by K EN G RAUER, MD ( 11/19 /2024 ): == Today's initial ECG provides yet another example of a tracing with a " Quick " Answer — as well as a slower , more complete Answer.

OR 69

OR STEMI Coronary CAD 69

Dr. Smith's ECG Blog

OCTOBER 17, 2024

Coronaries were normal, as was serial troponin. I sent the initial ECG of both cases without any context to my colleague Mazen El-Baba, a senior EM resident with an interest in ECG interpretation, and he responded: “RBBB with first degree AV block” for the first (ie no acute coronary occlusion), and “RBBB and superimposed OMI” for the second.

STEMI 73

STEMI Paramedic Coronary ED 73

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 106

EMS CPR ED Coronary 106

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 102

STEMI Coronary ACS ED 102

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

Here is the post shock ECG: Cardiology was called stat for ischemic VT, query SCAD vs thrombotic occlusion vs coronary vasospasm. Cath lab was activated: There was no coronary artery disease, but there was spontaneous coronary artery dissection (SCAD) of the distal LAD, which was narrowed by 95%, and treated medically.

OR 66

OR STEMI ACS Coronary 66

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 85

Coronary OR STEMI EMS 85

Dr. Smith's ECG Blog

JUNE 19, 2024

The ED provider ordered a coronary CT scan to assess the patient for CAD. The patient was taken emergently to the cath lab for a pericardiocentesis instead of a coronary angiogram. A troponin T was drawn at 1229 and resulted slightly elevated at 23 ng/L (URL for men in this assay is 15 ng/L).

STEMI 60

STEMI Coronary CAD ED 60

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 113

Defibrillator Coronary ALS STEMI 113

Dr. Smith's ECG Blog

NOVEMBER 10, 2024

My Comment , by K EN G RAUER, MD ( 11/10 /2024 ): = Think of today's case as a check of your skill in recognizing when to activate the cath lab. As emphasized by Dr. Smith in the November 8, 2024 post — as many as 1/3 of all acute STEMIs reperfuse spontaneously before treatment is implemented.

STEMI 81

STEMI OR ED EMS 81