Dr. Smith's ECG Blog

JUNE 5, 2024

Why Was Cardiac Cath Negative for Coronary Disease? As noted by Dr. Nossen — this patient qualified as MINOCA ( M yocardial I nfarction with N on- O bstructive C oronary A rteries ) — since troponin was positive on his 2nd admission, yet there was no evidence of obstructive coronary disease on cath.

Coronary 106

Coronary ACS ALS OR 106

The Skeptics' Guide to EM

SEPTEMBER 28, 2024

Date: September 23, 2024 Reference: Essat et al. The patient has no specific risk factors for acute coronary syndrome (ACS) or dissection. Reference: Essat et al. Diagnostic Accuracy of D-Dimer for Acute Aortic Syndromes: Systematic Review and Meta-Analysis.

Emergency Department 201

Emergency Department ACS Coronary ALS 201

REBEL EM

SEPTEMBER 21, 2023

What Your Gut Says: The patient has a tachydysrhythmia which may be the presentation of acute coronary syndrome (ACS) even though the patient has no ischemic symptoms. Essentially, we are using the troponin assay to find patients with ACO who may be benefited by coronary interventions or risk factor modification.

Coronary 143

Coronary ACS ED OR 143

EM Didactic

JANUARY 27, 2019

Myth 1 Absence of Classic Chest Pain obviates the need for ACS work up The absence of chest pain in no way excludes the diagnosis of ACS. Around 33-50% of the patients with ACS present to the hospital without chest pain. References: Canto JG, Shlipak MG, Rogers WJ, et al. Dorsch MF, Lawrence RA, Sapsford RJ, et al.

ACS 52

ACS ALS Coronary Emergency Department 52

EMS 12-Lead

JUNE 20, 2022

Although the attending crews did not consider the ECG pathognomonic for occlusive thrombosis, they nonetheless considered the patient high-risk for ACS and implored him to reconsider. One cannot rely on this feature as a means of detecting changes – subtle, or dramatic – for volatile occlusive coronary thrombus. 2] Driver, B.

ACS 130

ACS Coronary STEMI CAD 130

The Skeptics' Guide to EM

JANUARY 18, 2020

Date: January 16th, 2020 Reference: Troponin Testing and Coronary Syndrome in Geriatric Patients With Nonspecific Complaints: Are We Overtesting? Date: January 16th, 2020 Reference: Troponin Testing and Coronary Syndrome in Geriatric Patients With Nonspecific Complaints: Are We Overtesting? Reference: Wang et al.

ACS 130

ACS Coronary Emergency Department OR 130

The Skeptics' Guide to EM

SEPTEMBER 11, 2021

Date: September 8th, 2021 Reference: Desch et al. Date: September 8th, 2021 Reference: Desch et al. Defibrillation is the treatment of choice in these cases but does not often result in sustained ROSC ( Kudenchuk et al 2006). Acute coronary syndrome (ACS) is responsible for the majority (60%) of all OHCAs in patients.

EMR 130

EMR Coronary Defibrillator Life Support 130

Dr. Smith's ECG Blog

JUNE 17, 2024

In fact, Kosuge et al. 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. “The

E-9-1-1 136

E-9-1-1 ACS Emergency Department Coronary 136

ACEP Now

DECEMBER 11, 2023

Many conditions outside of acute coronary syndrome (ACS) mimic ST-elevation myocardial infarction (STEMI), but only a handful of cases have reported ST-elevations (STE) in the setting of pancreatic inflammation where underlying ACS was excluded. 2 Proposed hypothesis as described by Hsu et al.,

STEMI 52

STEMI Coronary ACS Critical Care 52

Dr. Smith's ECG Blog

AUGUST 9, 2019

Post by Smith and Meyers Sam Ghali ( [link] ) just asked me (Smith): "Steve, do left main coronary artery *occlusions* (actual ones with transmural ischemia) have ST Depression or ST Elevation in aVR?" She had a proven 100% Left Main occlusion No ST shift in aVR This pattern of RBBB/LAFB was also the most common pattern in Fiol et al.

Coronary 52

Coronary STEMI ACS ALS 52

EMS 12-Lead

APRIL 14, 2022

It should be emphasized here that this is a presentation of high-pretest probability for Acute Coronary Syndrome (ACS). ACS and hyperkalemia both have lethal downstream consequences, so it is imperative for the clinician to acclimate to the presentation, or developing, features of each. link] [1] Zachary et al.

ACS 130

ACS Paramedic Coronary ALS 130

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. Amsterdam et al. Alencar et al.

STEMI 117

STEMI Coronary ALS CAD 117

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

Smith: If this is ACS (a big if), t his is just the time when one should NOT use "upstream" dual anti-platelet therapy ("upstream" means in the ED before angiography). History sounds concerning for ACS (could be critical stenosis, triple vessel), but differential also includes dissection, GI bleed, etc. Anything more on history?

ACS 52

ACS Coronary STEMI ALS 52

EMS 12-Lead

APRIL 21, 2022

There is appreciable STE aVR with near-global STD that appropriately maximizes in Leads II and V5, and thus suggesting a circumstance of generic, diffusely populated, circumferential subendocardial ischemia versus occlusive coronary thrombus. [1] It’s judicious, then, to arrange for coronary angiogram. link] [1] Mirand, D.

Coronary 130

Coronary ALS OR ACS 130

ACEP Now

JUNE 6, 2023

Notoriously elusive, with a high misdiagnosis rate, thoracic aortic dissection (AD) can mimic many conditions, including acute coronary syndrome (ACS, the most common), gastroesophageal reflux disease (GERD), stroke, and spinal-cord compression. ACS is the most common misdiagnosis and often leads to inappropriate anticoagulation.

ACS 85

ACS ALS ED OR 85

EMS 12-Lead

JUNE 1, 2022

Such findings would normally suggest primary ischemia with concomitant surveillance of coronary occlusion, but these ST/T changes might very well be secondary to the Escape mechanism at hand. Evaluation of T-wave morphology in patients with left bundle branch block and suspected acute coronary syndrome. 3] Meyers, H. 4] Dodd, K.

Coronary 130

Coronary ALS ACS ED 130

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

In our opinion it should not be given in ACS unless you are committed to the cath lab. Learning Point: Any NSTEMI patient with active ongoing ACS symptoms refractory to medical management is supposed to go to the cath lab within 2 hours if available, per all guidelines in world, regardless of ECG findings. 2009;95:1701–1706.

ACS 82

ACS Coronary ALS CAD 82

The Skeptics' Guide to EM

MAY 28, 2022

Date: May 24th, 2022 Reference: Broder et al. Date: May 24th, 2022 Reference: Broder et al. Reference: Broder et al. Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE) 2: Low-Risk, Recurrent Abdominal Pain in the Emergency Department.

Emergency Department 100

Emergency Department ACS ALS Coronary 100

Dr. Smith's ECG Blog

DECEMBER 19, 2023

The commonest causes of MINOCA include: atherosclerotic causes such as plaque rupture or erosion with spontaneous thrombolysis, and non-atherosclerotic causes such as coronary vasospasm (sometimes called variant angina or Prinzmetal's angina), coronary embolism or thrombosis, possibly microvascular dysfunction. This is not the case.

E-9-1-1 118

E-9-1-1 Coronary ACS BLS 118

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

The fire department, who operate at an EMT level in this municipality, arrived before us and administered 324 mg of baby aspirin to the patient due to concern for ACS. Reference on Troponins: Xenogiannis I, Vemmou E, Nikolakopoulos I, et al. One need not have obstructive coronary disease to have occlusive thrombus!

Emergency Department 52

Emergency Department E-9-1-1 Coronary STEMI 52

REBEL EM

JANUARY 29, 2024

Click here for Direct Download of the Podcast Paper: Aykan AC et al. References: Jaff MR et al. PMID: 21422387 Wan S et al. PMID: 15262836 Sharifi M et al. PMID: 27422214 Wang C et al. PMID: 19741062 Kucher N et al. PMID: 24226805 Piazza G et al. PMID: 26315743 Tapson VF et al.

ALS 137

ALS ACS OR CPR 137

Dr. Smith's ECG Blog

DECEMBER 27, 2023

Note that as many as 7% of patients with acute coronary syndrome have chest pain reproducible on palpation [Lee, Solomon]. which reduces the pre-test probability of acute coronary syndrome by less than 30% [McGee]. The original term " benign early repolarization" has fallen out of favor since the seminal paper by Haïssaguerre et al.

E-9-1-1 116

E-9-1-1 OR Coronary ACS 116

Dr. Smith's ECG Blog

AUGUST 9, 2024

Serial ECGs enhance the diagnosis of acute coronary syndrome. Similarly, the OMI paradigm respects ACS as a dynamic process in which ECG changes reflect the phase of myocardial injury and risk stratify which patients may benefit from emergent PCI. Bigger et al. Sadowski ZP, Alexander JH, Skrabucha B, et al.

STEMI 84

STEMI Coronary Heart Attack ACS 84

EMS 12-Lead

APRIL 8, 2022

Cardiology admitted him for observation with plans for next-day coronary angiogram. Smith and Meyers found that patients presenting with high-risk ACS and any ST-depression, even less than 1 mm, maximal in leads V1-V4 to be 97% specific for OMI and 96% specific for OMI requiring emergent PCI. [5] 1] Driver, B. 2] van Gorselen, E.,

STEMI 130

STEMI ALS Coronary CAD 130

Dr. Smith's ECG Blog

JUNE 19, 2023

Armstrong et al. The patient has also developed sinus bradycardia, which may result from right coronary artery ischemia to the SA node. Angiogram showed a culprit lesion of 100% stenosis to the right coronary artery and 100% stenosis of the right posterior descending artery, both with TIMI 0 flow. Just another NSTEMI.

STEMI 52

STEMI ACS Coronary Defibrillator 52

ACEP Now

MARCH 14, 2024

Current can be alternating current (AC) or direct current (DC) with AC typically more dangerous as it is more likely to cause tetanic contractions and increase contact time with the electrical source. 2,3,5 Except for laundry or electrical car outlets (240 V AC), all U.S. household outlets are rated at 120 V AC.

Operating Room 52

Operating Room ACS Critical Care Coronary 52

Dr. Smith's ECG Blog

JANUARY 27, 2024

There were zero patients in this study with a "normal" ECG who had any kind of ACS! 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. Deutch et al. So this study is actually worthless.

STEMI 101

STEMI Coronary ACS ED 101

Dr. Smith's ECG Blog

OCTOBER 24, 2019

The biphasic T wave is consistent with recent reperfusion of an occluded coronary artery supplying the inferior region. Here’s the angiogram of the RCA : No thrombus or plaque rupture in the RCA (or any coronary artery) was found. This MI wasn’t caused by a ruptured plaque of CAD - it was a coronary artery dissection of the RCA.

Coronary 52

Coronary CAD ACS STEMI 52

Dr. Smith's ECG Blog

JULY 27, 2023

I did not think it was due to ACS, but we ordered an ED ECG immediately: What do you think? But in this case the clinical scenario is not right for acute ACS with OMI, and there is very high voltage, and the patient is very young, (though beware of young patients , even 29 year olds!! I was not worried for a coronary etiology.

Coronary 52

Coronary ACS Naloxone Plasma 52

Dr. Smith's ECG Blog

MAY 13, 2020

Here is the EMS ECG: Obviously massive diffuse subendocardial ischemia, with profound STD and STE in aVR Of course this pattern is most often seen from etoliogies other than ACS. The case I presented in My Comment to that March 9, 2020 post showed a patient with this pattern — who on cath had no more than minimal coronary disease.

Coronary 52

Coronary ACS EMS STEMI 52

ECG & Echo Learning

OCTOBER 2, 2022

Below follows a drug manual for use in the CCU (coronary care unit), ICU (intensive care unit) or ER (emergency room). μg/kg/min + + + ++ Low dose dopamine stimulates D1 receptors and induces vasodilation in coronary, renal, cerebral and mesenteric vessels. Increases coronary blood flow. Coronary flow enhanced.

E-9-1-1 52

E-9-1-1 ALS Coronary Epinephrine 52

Dr. Smith's ECG Blog

JANUARY 5, 2024

Thus, these troponins are very concerning for ACS, and subsequent ones will probably be diagnostic of acute MI. Heitner et al. We know that even high-sensitivity troponin may not exceed the "normal" range for a period of hours in certain patients with acute coronary occlusion. DOI:10.1161/CIRCINTERVENTIONS.118.007305),

ACS 106

ACS ALS OR STEMI 106

ACEP Now

AUGUST 12, 2024

Considering hyperacute T-waves have been accepted as STEMI equivalents, it is possible that pseudonormalization could gain more recognition as an indicator of ACS. Sequence of events in angina at rest: Primary reduction in coronary flow. Normalization of abnormal T waves in ischemia. Arch Intern Med. 1976 Apr;136(4):391-5. Circulation.

Emergency Department 52

Emergency Department STEMI ACS ED 52

Dr. Smith's ECG Blog

MAY 31, 2023

-See this study showing an association between morphine and mortality in ACS: Use of Morphine in ACS is independently associated with mortality, at odds ratio of 1.4. Association of intravenous morphine use and outcomes in acute coronary syndromes: Results from the CRUSADE Quality Improvement Initiative.

STEMI 81

STEMI Coronary ACS OR 81

EMS 12-Lead

APRIL 2, 2022

He reported a history of ischemic cardiomyopathy with coronary stent placement approximately 10 years prior, but could not recall the specific artery involved. Anecdotally, had there been symptoms unequivocally consistent with ACS then one could justifiably make the case for a potential D1 occlusion. 4] Baranchuk, A, et al.

ALS 130

ALS STEMI Coronary OR 130

Dr. Smith's ECG Blog

MAY 8, 2023

The ACC likely made this new recommendation for the MSC in ventricular paced rhythm in large part due to the "PERFECT" Study (Meyers is an author, and Smith was the senior author): Dodd et al. Electrocardiographic Diagnosis of Acute Coronary Occlusion Myocardial Infarction in Ventricular Paced Rhythm Using the Modified Sgarbossa Criteria.

STEMI 52

STEMI Coronary ED ACS 52

Dr. Smith's ECG Blog

JANUARY 6, 2023

Lupu L, et al. Immediate and early percutaneous coronary intervention in very high-risk and high-risk Non-STEMI patients. Smith comment: We have shown that use of opiates is associated with worse outcomes in ACS: Bracey, A. Opioids in ACS may reduce the pain score, but do not provide reperfusion for ongoing ACS.

ACS 52

ACS Coronary ICU STEMI 52