Dr. Smith's ECG Blog

JULY 2, 2023

This was texted to me from a former resident, while working at a small rural hospital, with the statement: "I can’t convince myself of anything here, but he’s a 63-year-old guy with prior stents and a good story for ACS." Thank you for your work with the artificial intelligence and the blog to make people better at this.

ACS 52

ACS Coronary OR 52

Dr. Smith's ECG Blog

MARCH 14, 2024

These have all been small studies, studying very few patients with ACS, and often used final cardiology interpretation rather than patient outcome. Smith : This study had such low risk patients that not a single patient was ultimately diagnosed with ACS. It is well known that NOMI usually has a normal ECG or nonspecific ECG.

STEMI 119

STEMI ACS Coronary Emergency Department 119

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. ECG's are difficult. link] [1] Zachary et al.

ACS 130

ACS Paramedic Coronary ALS 130

Dr. Smith's ECG Blog

DECEMBER 27, 2023

Brief aside: "Early repolarization" is a frequently proclaimed and poorly understood electrocardiographic phenomenon which mostly serves to reassure clinicians that not all ST elevations are ischemic (something readers of this blog know well). It relies on an 1 mm cut point, which this blog does not favor as an approach to ECG.

E-9-1-1 130

E-9-1-1 OR Coronary ACS 130

Dr. Smith's ECG Blog

OCTOBER 26, 2010

ACS and STEMI generally do not cause tachycardia unless there is cardiogenic shock. Then ACS (STEMI) might be primary; this might be cardiogenic shock. One must clearly rule out these processes before jumping on the ACS diagnosis. Are the lungs clear? Is the patient cool and pale?

ACS 52

ACS STEMI OR Critical Care 52

Dr. Smith's ECG Blog

OCTOBER 4, 2010

ACS would be highly unusual in a young athlete, and given the information on his race bib, one must first suspect that the abnormal ST elevation is due to demand ischemia, not ACS. A bedside echo performed by the emergency physician showed no wall motion abnormality and confirmed LVH.

ACS 52

ACS Epinephrine Defibrillator STEMI 52

Broome Docs

DECEMBER 22, 2024

You can find more details in the full blog post. PECARN looks at probiotics for toddlers diarrhea… Schnadower D, Tarr PI, Casper TC, Gorelick MH, Dean JM, O’Connell KJ, Mahajan P, Levine AC, Bhatt SR, Roskind CG, Powell EC, Rogers AJ, Vance C, Sapien RE, Olsen CS, Metheney M, Dickey VP, Hall-Moore C, Freedman SB.

E-9-1-1 52

E-9-1-1 ACS Paramedic Emergency Department 52

Broome Docs

JANUARY 27, 2025

Full blog post here. PMID: 39461792 Bottom line: The WOMAN 2 trial is a large double-blind RCT that shows no benefit of TXA in the prevention of postpartum hemorrhage, which fits with all of the existing literature demonstrating no role for TXA in the management of postpartum hemorrhage. Emerg Med J. 2019 Jan;36(1):2-3. Epub 2018 Oct 25.

ED 101

ED OR ACS Critical Care 101

Dr. Smith's ECG Blog

MAY 20, 2024

This was sent by an undergraduate (not yet in medical school, but applying now) who works as an ED technician (records all EKGs, helps with procedures, takes vital signs) and who reads this blog regularly. Smith comment : Is the ACS (rupture plaque) with occlusion that is now reperfusing? The ST depressions in I and aVL have resolved.

CAD 125

CAD STEMI Coronary ACS 125

Dr. Smith's ECG Blog

MARCH 31, 2024

The person I was texting knows implicitly based on our experience together that I mean "Definite posterior OMI, assuming the patient's clinical presentation is consistent with ACS." The patient was a middle-aged female who had acute chest pain of approximately 6 hours duration. The pain was still active at the time of evaluation.

STEMI 110

STEMI ACS ED 110

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 98

STEMI ACS OR ALS 98

Dr. Smith's ECG Blog

APRIL 9, 2024

ACS then becomes less likely. Keep an eye on the blog as an OMI QUIZ soon will be published where you test yourself vs the Queen! On arrival patient was slightly tachycardic. HR about 90-100/min. Other vital signs normal. Hand held echo showed overall ejection fraction being normal. With normal EF the tachycardia is not compensatory.

Coronary 108

Coronary CAD ACS OR 108

Dr. Smith's ECG Blog

FEBRUARY 9, 2024

If there were diffuse ischemic STD, with precordial STDmaxV5-6 and reciprocal STE-aVR, this would be non-specific subendocardial ischemia from ACS or supply-demand mismatch. The new ESC guidelines has for the first time merged both STEMI and non-STEMI in the same guideline because they are both on the spectrum of ACS.

STEMI 114

STEMI ACS Coronary OR 114

Dr. Smith's ECG Blog

DECEMBER 19, 2023

Because there was proven thrombus (ACS) but the troponin never went above the 99% reference range (and therefore cannot be called MI -- definition of MI requires rise and/or fall of troponin with at least one value above the 99% reference range), this is UNSTABLE ANGINA with ST Elevation. A picture is worth 1,000 words.

E-9-1-1 127

E-9-1-1 Coronary ACS BLS 127

EMOttawa

DECEMBER 18, 2023

2023 Oct 1;8(10):946-956 Question: Does the modified GRACE score incorporating continuous troponin improve ACS risk prediction? The post Modification of the GRACE Risk Score for Risk Prediction in Patients With Acute Coronary Syndromes appeared first on EMOttawa Blog. JAMA Cardiol. Methods: Retrospective.

Coronary 52

Coronary ACS ALS 52

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

Angiogram No obstructive epicardial coronary artery disease Cannot exclude non-ACS causes of troponin elevation including coronary vasospasm, stress cardiomyopathy, microvascular disease, etc. Most studies examine undifferentiated ACS cohorts, with only a handful providing separate data. References: 1.

Coronary 109

Coronary E-9-1-1 STEMI ACS 109

REBEL EM

MAY 29, 2024

VS abnormalities can drive this as well Strongly consider reversal of AC (this will typically come after control) Stopping the Bleeding PPE: these things bleed like stink. Rezaie, MD (Twitter/X: @srrezaie ) The post REBEL Core Cast 123.0 – Posterior Epistaxis appeared first on REBEL EM - Emergency Medicine Blog.

ICU 102

ICU ALS ACS EMS 102

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. Evidence regarding intervention to non-culprit plaques is mixed and beyond the scope of this blog post. Thus, one considers a test result that varies by 2 or less to be the same result. Heitner et al.

ACS 120

ACS ALS OR STEMI 120

Dr. Smith's ECG Blog

JANUARY 9, 2024

Ischemia from ACS causing the chest discomfort, with VT another consequence (or coincidence)? Cardioversion will address the rhythm problem immediately, also if the chest discomfort subsides when SR is restored, ischemia from ACS becomes much less likely. In either case, prompt cardioversion is indicated.

Coronary 119

Coronary ACS ED OR 119

Dr. Smith's ECG Blog

NOVEMBER 14, 2023

As is often emphasized on Dr. Smith's ECG Blog — the evolution of an acute OMI is not necessarily static — but may be "dynamic". For examples of this phenomenon — See My Comment in the February 14, 2018 — July 21, 2020 — and December 22, 2022 posts in Dr. Smith's ECG Blog ). So they looked into the patient's chart.

E-9-1-1 116

E-9-1-1 Coronary EMS ED 116

Dr. Smith's ECG Blog

APRIL 18, 2024

Non-STEMI guidelines call for “urgent/immediate invasive strategy is indicated in patients with NSTE-ACS who have refractory angina or hemodynamic or electrical instability,” regardless of ECG findings.[1] 1] European guidelines add "regardless of biomarkers". But only 6.4%

STEMI 121

STEMI Coronary ALS CAD 121

REBEL EM

OCTOBER 23, 2023

Follow up with the dentist in the morning Reinsert the tooth and avoid solid food Reinsert the tooth and stabilize it with a bridge Remove the tooth and repair the gingival laceration Remove the tooth and wrap it in saline-soaked gauze FOR THE RIGHT ANSWER CLICK ON THE ROSH REVIEW LOGO BELOW References Day PF, Flores MT, O’Connell AC, et al.

EMS 58

EMS ACS ALS ED 58

Dr. Smith's ECG Blog

OCTOBER 12, 2024

Click here to sign up for Queen of Hearts Access Given the lack of intracranial hemorrhage, the patient was administered aspirin for suspected ACS and cardiology was consulted. For a list of lead reversal cases we've discussed in Dr. Smith's ECG Blog — GO TO the bottom of the page in My Comment from the January 6, 2024 post).

STEMI 115

STEMI Coronary Emergency Department OR 115

REBEL EM

SEPTEMBER 11, 2023

ACS surgeons appeared to select surgery as their initial choice substantially more frequently than other subspecialties. ACS surgeons would have sent 6/43 patients for ERCP or MRCP (14%), whereas surgical oncologists would have sent a higher percentage of patients for ERCP or MRCP (7/18 or 38.9%).

ED 68

ED ACS Emergency Department OR 68

Dr. Smith's ECG Blog

FEBRUARY 2, 2024

He has been following the blog for 4 years. The app also states that there is "suspected" ACS without ST elevation (NSTEMI), posterior fascicular block, sinus bradycardia, and LVH) Note on version 1 of the Queen: she will diagnose "OMI" whether it is an active or reperfused OMI. He wanted to share one of the first cases.

STEMI 85

STEMI ACS OR 85

Dr. Smith's ECG Blog

MARCH 26, 2024

We have seen this pattern in many pts with acute right heart strain on this blog. __ Smith : The combination of T-wave inversion in V1-V3 and in lead III is very specific for acute pulmonary embolism. Moreover, what I call "domed" T-wave inversion in V1-V3 is typical for acute PE and NOT typical of ACS (i.e.,

ACS 68

ACS OR 68

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

References: 1) See this study showing an association between morphine and mortality in Non-STE-ACS: Meine TJ, Roe M, Chen A, Patel M, Washam J, Ohman E, Peacock W, Pollack C, Gibler W, Peterson E. Link to abstract Link to full text 2) Use of Morphine in Non-STE-ACS is independently associated with mortality, at odds ratio of 1.4

E-9-1-1 78

E-9-1-1 ACS STEMI Coronary 78

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.

ACS 82

ACS Coronary ALS CAD 82

Dr. Smith's ECG Blog

JULY 11, 2024

Because: 1) He has been reading this blog for a long time. Editorial Comment: I begin my thoughts on today's Blog post with the above reflections to provide perspective for my concerns about this case. This is another case sent by the undergraduate (who is applying to med school) who works as an EKG tech.

Coronary 112

Coronary ED ACS OR 112

Dr. Smith's ECG Blog

OCTOBER 15, 2023

Taking a Closer LOOK: We have periodically reviewed cases with low voltage in Dr. Smith’s ECG Blog ( Please see My Comment at the bottom of the page in the November 12, 2020 post, among others ). Among the causes of low voltage that I note in this Nov.

ACS 116

ACS ED STEMI OR 116

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! This defies all previous data on acute MI which would show that even undetectable troponins do not have a 100% negative predictive value. So this study is actually worthless.

STEMI 117

STEMI Coronary ACS ED 117

Dr. Smith's ECG Blog

FEBRUARY 28, 2020

Some providers were worried about ACS because of this ECG. My answer alleviated their concern for ACS and no further workup was done for ACS. showed that , when T-waves are inverted in precordial leads, if they are also inverted in lead III and V1, then pulmonary embolism is far more likely than ACS. Kosuge et al.

E-9-1-1 52

E-9-1-1 ACS ALS OR 52

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

Dr. Smith's ECG Blog

JULY 3, 2018

The AHA/ACC guidelines recommend emergent cardiac catheterization for patients with concern for ACS and refractory chest pain despite maximum medical therapy defined as aspirin + clopidogrel/ticagrelor + heparin/enoxaparin. link] He was admitted to the cardiology unit for serial troponin measurements and concern for possible ACS.

ACS 52

ACS STEMI Coronary CAD 52

Dr. Smith's ECG Blog

MARCH 27, 2025

But there are also hyperacute T waves (HATW) in V4-5, which exclude early repolarization and pericarditis, leaving only LAD occlusion for this patient presenting with classic symptoms of ACS. It's not that today's oversights are unique but rather that: i ) The errors of omission and commision in today's case are multiple and preventable.

STEMI 80

STEMI Coronary ACS OR 80

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. I have posted previous such cases, but in searching my own blog, I could not find them. The ECG only tells you there is ischemia, not the etiology of it.

Coronary 52

Coronary ACS EMS ALS 52

Dr. Smith's ECG Blog

MARCH 27, 2023

This is now further confirmation of ACS. The ACC/AHA guidelines mandate less than 2 hours cath for patients with ACS with refractory pain, pulmonary edema, or electrical or hemodynamic instability. Another ECG was recorded at 160 minutes: There is evolution, with worsening of ischemia.

ACS 52

ACS STEMI OR 52