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

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-9-1-1 114

E-9-1-1 Coronary STEMI ALS 114

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

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 119

Coronary STEMI ED OR 119

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 106

OR STEMI ICU Coronary 106

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 70

OR STEMI ACS Coronary 70

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 77

Coronary STEMI ED OR 77

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 91

STEMI Coronary Defibrillator OR 91

Dr. Smith's ECG Blog

JANUARY 2, 2025

Among patients with left bundle branch block, T-wave peak to T-wave end time is prolonged in the presence of acute coronary occlusion. Finally, do a coronary angiogram Possible alternative to pacing is to give a beta-1 agonist to increase heart rate. T-waves are quite tall and possibly peaked (HyperK?), but potassium returned normal.

Coronary 87

Coronary OR Defibrillator ALS 87

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-9-1-1 109

E-9-1-1 Coronary ALS ED 109

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 89

Coronary CAD ACS OR 89

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 75

OR E-9-1-1 Coronary 75

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 95

STEMI Coronary OR EMS 95

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 107

Coronary CAD CPR Critical Care 107

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 70

OR Coronary ACS EMS 70

Dr. Smith's ECG Blog

DECEMBER 3, 2024

Given the right coronary anatomy seen during angiography, it is particularly interesting that subtle T wave changes were seen on the previous EKGs in the high lateral leads that would otherwise only be expected with a more proximal RCA lesion. Another EKG was also obtained. Also: electrical instability, pulmonary edema, or hypotension.

ED 94

ED Coronary ACS STEMI 94

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 107

Coronary STEMI Emergency Department OR 107

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 96

STEMI Coronary Emergency Department ACS 96

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 100

STEMI Coronary ACS ED 100

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 95

OR Coronary ALS 95

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 91

Defibrillator STEMI Coronary ALS 91

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 75

Defibrillator ALS Coronary OR 75

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 112

Defibrillator Coronary ALS STEMI 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 70

STEMI Coronary ALS OR 70

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 77

STEMI Coronary Paramedic EMS 77

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 75

EMS E-9-1-1 Operating Room OR 75

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 112

STEMI Coronary Emergency Department OR 112

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. What is your interpretation? It is shown below.

Coronary 98

Coronary OR ALS 98

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 70

Coronary STEMI OR ALS 70

Dr. Smith's ECG Blog

DECEMBER 16, 2024

Cardiology wanted a CT of the aorta to rule out dissection, presumably partly due to the very high blood pressure readings, but also because it is hard for people to believe that a 20-something woman could have acute thrombotic coronary artery. They also recommended a NTG drip, after which she reported complete resolution of pain. Denies SOB.

STEMI 85

STEMI Coronary Critical Care ED 85

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 98

Coronary ACS ED OR 98

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 88

ALS Coronary Emergency Department ED 88

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-9-1-1 106

E-9-1-1 Coronary EMS ED 106

Dr. Smith's ECG Blog

DECEMBER 6, 2024

Angiogram: Severe two-vessel coronary artery disease of a left dominant system including 70 to 80% stenosis involving the distal left main/bifurcation. Case continued Troponins over 26 hours, from right to left : Echocardiogram: Mild concentric left ventricular wall thickening, normal cavity size, and normal systolic function. or 3 hours?

Coronary 98

Coronary ED OR 98

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. There are many reasons that this ECG is diagnostic of LAD OMI.

Coronary 93

Coronary ED ACS OR 93

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 104

EMS CPR ED Coronary 104

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 82

Coronary OR STEMI EMS 82