Dr. Smith's ECG Blog

NOVEMBER 11, 2024

Learning points: Mobitz I and Mobitz II can co-exist in the same patient at the same time Bedside maneuvers can help clarify the etiology of 2:1 AV block == MY Comment , by K EN G RAUER, MD ( 11/10 /2024 ): == Questions often arise regarding the various forms of 2nd-degree AV block. See Ken Grauer 's comment below for more on this.

OR 71

OR E-9-1-1 Coronary 71

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 127

Coronary ACS Emergency Department Defibrillator 127

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. or is he an ACCESS Trial Candidate? == MY Comment , by K EN G RAUER, MD ( 7/5 /2024 ): == Clinical ECG interpretation is a 2-Step process. It also does not uniformly indicate severe coronary disease.

Defibrillator 115

Defibrillator Coronary Epinephrine ACS 115

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 84

STEMI Coronary Defibrillator OR 84

Dr. Smith's ECG Blog

SEPTEMBER 9, 2024

You can easily imagine this patient getting one of several diagnoses -- vasospasm, MINOCA , pericarditis, or maybe even no diagnosis at all beyond "non-obstructive coronary artery disease." Another option would be to use Optical Coherence Tomography for Coronary Imaging ). That plaque is at risk of thrombosing again.

OR 66

OR Coronary ACS EMS 66

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 120

STEMI Coronary ALS CAD 120

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 113

OR STEMI ICU Coronary 113

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. It’s time to learn smarter. Am J Emerg Med. doi: 10.1016/j.ajem.2023.10.049.

Coronary 76

Coronary STEMI ED OR 76

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 120

ED Coronary Paramedic OR 120

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 ). What do you do clinically when the ECG looks like this?

E-9-1-1 115

E-9-1-1 Coronary STEMI ALS 115

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 ). This was sent to me from Sam Ghali ( @EM_Resus ) with no other information.

E-9-1-1 115

E-9-1-1 Coronary ALS ED 115

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 121

STEMI Coronary ALS Emergency Department 121

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 96

Coronary CAD ACS OR 96

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 103

STEMI Coronary Emergency Department OR 103

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. Just not yet. So WHY wait? As per Drs.

STEMI 81

STEMI OR ED EMS 81

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. 2 Normal ECG #3.

STEMI 102

STEMI Coronary OR EMS 102

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. You must record frequent serial ECGs for patients with chest pain. Every 15 minutes! R wave progression is normal.

Coronary 66

Coronary STEMI OR ALS 66

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. Pattern A evolves into Pattern B. Am Heart J. 2000;139:430–436. Am J Cardiol.

Coronary 118

Coronary STEMI ED OR 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-9-1-1 138

E-9-1-1 ACS Emergency Department Coronary 138

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 119

STEMI ED Coronary EMS 119

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. Here is an example of that.

Defibrillator 79

Defibrillator ALS Coronary OR 79

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

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 113

Coronary STEMI Emergency Department OR 113

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 112

Coronary CAD CPR Critical Care 112

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

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. We’ll keep it short, while you keep that EM brain sharp. Vital signs include BP 90/48, HR 122, T 98.3

EMS 74

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

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 82

ACS Coronary STEMI OR 82

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 patient like this one would not be enrolled because no clinician (ER doc or cardiologist) would enroll such a patient. This study failed to do so. 5% vs. 58%!!

Defibrillator 95

Defibrillator STEMI Coronary ALS 95

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 78

STEMI Paramedic Coronary EMS 78

FOAMfrat

JUNE 25, 2024

Since then, I’ve developed a habit for outdoor recreation and light versions of mountaineering, which led me to realize that altitude illness can occur in much less extreme conditions than I’d previously thought and that these pathophysiologies might actually be relevant to those of us not living in Nepal.

OR 97

OR Coronary ALS 97

Dr. Smith's ECG Blog

OCTOBER 17, 2024

Coronaries were normal, as was serial troponin. Among others — See My Comment at the bottom of the page in the September 13, 2024 post of Dr. Smith's ECG Blog ). Written by Jesse McLaren Two patients in their 70s presented to the ED with chest pain and RBBB. Do either, both, or neither have occlusion MI? Take away 1.

STEMI 73

STEMI Paramedic Coronary ED 73

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 107

STEMI Coronary ACS ED 107

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 118

Defibrillator Coronary ALS STEMI 118

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. In any case, the ECG is diagnostic of severe ischemia and probably OMI. Concordant STE of 1 mm in just one lead or 2a.

Coronary 90

Coronary OR STEMI EMS 90

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). This is typical of pericarditis.

STEMI 60

STEMI Coronary CAD ED 60

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 87

ALS Coronary Emergency Department ED 87

Dr. Smith's ECG Blog

JANUARY 9, 2024

The patient is an older woman with known coronary disease and an ICD-Pacemaker implanted because of a history of VT ( V entricular T achycardia ). However , this patient is having chest discomfort, and by definition then she should be considered not to be stable. Is this: 1. In either case, prompt cardioversion is indicated.

Coronary 103

Coronary ACS ED OR 103