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-9-1-1 139

E-9-1-1 ACS Emergency Department ALS 139

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

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

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

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

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 121

STEMI Coronary ALS CAD 121

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

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?

Coronary 52

Coronary ACS 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 Firefighter OR 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 87

ACS Coronary ALS CAD 87

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-9-1-1 122

E-9-1-1 Coronary ACS BLS 122

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 88

STEMI Coronary Heart Attack ACS 88

Dr. Smith's ECG Blog

JUNE 8, 2023

According to the STEMI paradigm, the patient doesn’t have an acute coronary occlusion and doesn't need emergent reperfusion, so the paramedics can bring them to the ED for assessment, without involving cardiologists. STEMI criteria, and automated interpretations based on it, will miss acute coronary occlusion. Kontos et al.

STEMI 62

STEMI Coronary Paramedic ALS 62

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

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

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 104

STEMI Coronary ACS ED 104

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 ALS 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 109

ACS ALS OR STEMI 109

Dr. Smith's ECG Blog

SEPTEMBER 7, 2024

Lemkes et al. No wall motion abnormality This shows that significant ACS can have ZERO WMA!! A comparison of electrocardiographic changes during reperfusion of acute myocardial infarction by thrombolysis or percutaneous transluminal coronary angioplasty. The Proximal LAD thrombus lysed or partially lysed, restoring flow.

STEMI 115

STEMI ACS Critical Care OR 115

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 79

STEMI Coronary ACS OR 79

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

AUGUST 19, 2023

But because the patient had no chest pain or shortness of breath, it was not deemed to be from ACS. They were less likely to have STEMI on ECG, and more likely to be initially diagnosed as non-ACS. Dialysis patients have a high rate of ACS without chest pain and high rate of delayed diagnosis and delayed reperfusion 2.

STEMI 85

STEMI ACS OR ALS 85

Dr. Smith's ECG Blog

APRIL 8, 2022

The ECG is diagnostic for acute transmural infarction of the anterior and lateral walls, with LAD OMI being the most likely cause (which has various potential etiologies for the actual cause of the acute coronary artery occlusion, the most common of which is of course type 1 ACS, plaque rupture with thrombotic occlusion).

STEMI 52

STEMI Coronary ACS ED 52

Dr. Smith's ECG Blog

MARCH 12, 2018

Wellens pattern is a term which refers to coronary reperfusion morphology in the anterior leads) The best answer is because the entire gestalt of the ECG shows acute right heart strain instead, and just does not look like Wellens after you've seen Wellens hundreds of times. Stein et al. This is a paper worth reading : Marchik et al.

ACS 52

ACS Coronary ALS ICU 52

EMDocs

OCTOBER 21, 2023

A 68-year-old male with a past medical history of hypertension, diabetes mellitus, and coronary artery disease with a drug eluting stent placed 2 months ago presents with dizziness and vomiting that began 3 hours ago. The NIHSS cutoff that predicts outcomes is 4 points higher in AC compared with PC infarctions. Arch Neurol.

EMS 74

EMS ALS OR ACS 74

Dr. Smith's ECG Blog

APRIL 17, 2023

He had no symptoms of ACS. His HEAR score (before troponin resulted) was documented at 3, with documentation stating "low suspicion for ACS." A troponin this high in a patient with no known chronic troponin elevation, and active acute ACS symptoms, has a very high likelihood of type 1 ACS regardless of the ECG.

OR 52

OR STEMI ACS Emergency Department 52

Dr. Smith's ECG Blog

JANUARY 3, 2022

It was a 60yo with a history of stents to the circumflex and right coronary arteries, who presented with 9 hours of fluctuating central chest pain. This is step 4 : relying on the first troponin level to rule out acute coronary occlusion. 4] CT revealed no dissection but extensive coronary atherosclerosis. J of Emerg Med 2021.

STEMI 52

STEMI Coronary ALS ACS 52

EM Didactic

OCTOBER 7, 2018

Other possible reasons for higher levels could be: Pregnancy Coronary Artery Disease Viral Infections (10–40 mg/L) Bacterial infection (>40mg/dL) Malignancy, Obstructive Sleep Apnea, Connective Tissue Disorders Serial CRP measurements may be helpful to monitor a patient’s response to medical intervention. Normal levels increase with aging.

Emergency Department 40

Emergency Department ACS Critical Care Coronary 40

Dr. Smith's ECG Blog

AUGUST 3, 2017

It is our job to identify this entity and ensure these patients receive the same care they would for a STEMI in any other coronary artery territory. Therein lies the limitation of electrocardiography in diagnosing acute coronary occlusion. Matetzky S, Friemark D, Feinberg MS, et al. O'Gara et al. O'Gara et al.

STEMI 52

STEMI E-9-1-1 Coronary ALS 52

ALiEM

FEBRUARY 9, 2024

Intermediate-risk patients may be further stratified based on recent stress testing or coronary angiogram findings plus a modified HEART or Emergency Department Assessment of Chest Pain (EDACS) score. The patient has no previous stress testing or coronary angiogram, and he is not low risk by HEART or EDACS scoring.

E-9-1-1 276

E-9-1-1 ED Coronary ALS 276

Dr. Smith's ECG Blog

OCTOBER 3, 2018

When he showed it to me, I said "Ouch, looks like an acute coronary occlusion. no LBBB or paced rhythm), acute coronary occlusion MI (OMI) is diagnosed in approximately 75% of cases. Khan AR, Golwala H, Tripathi A, et al. What happened?" The medic recorded another 12-lead en route 13 minutes later: What do you think?

Coronary 52

Coronary STEMI Paramedic ALS 52

Dr. Smith's ECG Blog

OCTOBER 24, 2018

The patient would not have been diagnosed with acute coronary syndrome and would not have had an angiogram, would have been discharged (or perhaps had a stress test, which would be negative), and would be at great risk of another event, possibly resulting in death or heart failure. Thelin et al. Mokhtari et al.

E-9-1-1 52

E-9-1-1 STEMI ACS Coronary 52