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

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 94

Coronary CAD ACS OR 94

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 100

STEMI Coronary OR EMS 100

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 ALS 139

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

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 121

Coronary STEMI ED OR 121

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

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

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

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

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

SEPTEMBER 16, 2024

A coronary angiogram was done that did not show significant coronary artery disease. There are no clear signs of OMI. The patient was admitted and put telemetry. While on telemetry monitoring he suffered cardiac arrest and was resuscitated. What ECG finding may have contributed to (or precipitated) the cardiac arrest? There a two PVCs.

Defibrillator 70

Defibrillator Coronary OR ALS 70

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 108

EMS CPR ED Coronary 108

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 117

Defibrillator Coronary ALS STEMI 117

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 105

STEMI Coronary ACS ED 105

Dr. Smith's ECG Blog

SEPTEMBER 5, 2024

Another possible cause of pseudonormalization of T waves mentioned many times on this blog is the pseudonormalization caused by re-occlusion of an infarct related reperfused coronary artery. This does not fit with the clinical scenario in today's case. Below are two more video files. Hammill SC. Edwards WD.

STEMI 106

STEMI Coronary OR ALS 106

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 63

STEMI Coronary CAD ED 63

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 95

Coronary ED ACS OR 95

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

SEPTEMBER 7, 2024

A comparison of electrocardiographic changes during reperfusion of acute myocardial infarction by thrombolysis or percutaneous transluminal coronary angioplasty. PubMed PMID: 7778540. == MY Comment , by K EN G RAUER, MD ( 9/7 /2024 ): == The KEY to comparing to ECGs — is to put both ECGs next -to-each-other! Lemkes et al. Am Heart J.

STEMI 116

STEMI ACS Critical Care OR 116

Dr. Smith's ECG Blog

AUGUST 20, 2024

Record serial ECGs == MY Comment , by K EN G RAUER, MD ( 8/16 /2024 ): == It is always a challenge to interpret an ECGs from a patient with known coronary disease, but no prior tracing for comparison. Given the known history of coronary disease — multiple previous ECGs certainly were done. But it was called "TIMI-1" flow.

Coronary 67

Coronary OR 67

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. This can occur due to scar ( e.g. post infarct VT) or anatomical variants ( e.g. AVNRT or AVRT). In fact, use of antidyrhythimcs (e.g.,

STEMI 88

STEMI Coronary Heart Attack ACS 88

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 104

Coronary OR ALS 104

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-9-1-1 111

E-9-1-1 Coronary EMS ED 111

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

The Queen of Hearts AI app will hopefully be FDA approved in Q1 of 2024. The De Winter ECG pattern: morphology and accuracy for diagnosing acute coronary occlusion: systematic review. Immediate and early percutaneous coronary intervention in very high-risk and high-risk non-ST segment elevation myocardial infarction patients.

ACS 87

ACS Coronary ALS CAD 87

EMDocs

FEBRUARY 7, 2024

GLP-1 agonists are also associated with improved ejection fraction, coronary blood flow, and cardiac output while reducing the risk of cardiovascular events, infarction size, and all-cause mortality. The effects of GLP-1 agonists are associated with the dose. Higher doses of GLP-1 agonists are associated with weight loss.

Allergic Reaction 75

Allergic Reaction ALS CAD OR 75

Dr. Smith's ECG Blog

JANUARY 5, 2024

Sometimes it can take 12 or 24 hours to see ECG evidence of reperfusion. == MY Comment , by K EN G RAUER, MD ( 1/4/ 2024 ): == Superb and thorough discussion by Dr. Frick of today's case! A diagnosis of "reflux" or "GERD" is never supportable without a troponin rule out. His angiogram is shown below. Heitner et al.

ACS 110

ACS ALS OR STEMI 110

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 19, 2024

Immediate and early percutaneous coronary intervention in very high risk and high risk non-ST segment elevation myocardial infarction patients. Validation of the modified Sgarbossa criteria for acute coronary occlusion in the setting of left bundle branch block: A retrospective case-control study. Lupu et al. Clinical Cardiology.

Coronary 106

Coronary STEMI OR ALS 106

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 87

Coronary OR STEMI EMS 87

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 114

STEMI Coronary Emergency Department OR 114

Dr. Smith's ECG Blog

JANUARY 23, 2024

Even though the primary suspicion was not ischemic heart disease, a CT angiogram was performed, and it revealed normal coronary arteries. This ruled out coronary disease as the cause of conduction system disease. For the majority of the tracing there are two P waves for each QRS. There is a LBBB. Mobitz type II AV block was suspected.

Coronary 88

Coronary OR Defibrillator ALS 88

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 102

Coronary ACS ED OR 102

Dr. Smith's ECG Blog

MAY 3, 2024

See the variety of Left Main Occlusion ECGs here: How does Acute Total Left Main Coronary occlusion present on the ECG? == MY Comment , by K EN G RAUER, MD ( 5/3 /2024 ): == Most patients with acute LMain Occlusion do not survive to make it to the hospital. There is STE in aVR. Moreover, left main occlusion often presents near death.

ACS 118

ACS ED Coronary EMS 118

Dr. Smith's ECG Blog

JANUARY 17, 2024

Using the current paradigm, can you tell which patient had an acute coronary occlusion? STEMI vs OMI Now let’s see the rest of the ECG: can you tell which patient has an acute coronary occlusion, and which ECG has hyperacute T waves? Using T wave amplitude, can you tell which ECG has hyperacute T waves? You will get 5 free reports.

STEMI 103

STEMI Coronary ALS OR 103

ACEP Now

JUNE 14, 2024

Some of the critical differentials include pulmonary embolism, acute decompensated heart failure, pneumonia, pneumothorax, and acute coronary syndrome. Anginal chest pain, chest heaviness, or evidence of fluid overload suggest acute coronary syndrome or acute decompensated heart failure. Signs and symptoms of systemic infection (e.g.,

ALS 52

ALS Coronary OR Emergency Department 52

Don't Forget the Bubbles

DECEMBER 5, 2023

A very Merry Christmas from the BW team, and all the Best Wishes for 2024! With millions of journal articles published yearly, it is impossible to keep up. Our team have scoured the literature, so you don’t have to… or it might spark an interest to go and have a look at the full article. Br J Gen Pract. doi: 10.3399/BJGP.2023.0006.

Coronary 111

Coronary Epinephrine CPR Emergency Department 111