Dr. Smith's ECG Blog

APRIL 14, 2023

Sent by Anonymous, written by Pendell Meyers A man in his 60s with history of CAD and 2 prior stents presented to the ED complaining of acute heavy substernal chest pain that began while eating breakfast about an hour ago, and had been persistent since then, despite EMS administering aspirin and nitroglycerin. Pre-intervention.

CAD 52

CAD ACS STEMI Coronary 52

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

A man in his 70s with past medical history of hypertension, dyslipidemia, CAD s/p left circumflex stent 2 years prior presented to the ED with worsening intermittent exertional chest pain relieved by rest. In our opinion it should not be given in ACS unless you are committed to the cath lab.

ACS 83

ACS Coronary ALS CAD 83

Dr. Smith's ECG Blog

JULY 3, 2018

Submitted and written by Alex Bracey with edits by Pendell Meyers and Steve Smith Case A 50ish year old man with a history of CAD w/ prior LAD MI s/p LAD stenting presented to the ED with chest pain similar to his prior MI, but worse. 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

OCTOBER 10, 2022

If this is ACS with Aslanger's pattern , the ST depression vector of subendocardial ischemia (due to simultaneous 3 vessel or left main ACS) is directed toward lead II (inferior and lateral). Thus, this apparently is Aslanger's Pattern (inferior OMI with single lead STE in lead III, with simultaneous subendocardial ischemia).

ACS 52

ACS CPR CAD Heart Attack 52

Dr. Smith's ECG Blog

MARCH 20, 2023

So, I'm a follower of your blog, and I think I have a interesting case that I attended yesterday." Remember: these findings above are included as STEMI equivalent findings in the 2022 ACC Expert Consensus Decision Pathway on ACS Patients in the ED. Since then, I started looking for OMI EKG findings and not just STEMI.

STEMI 52

STEMI ACS CAD ED 52

Dr. Smith's ECG Blog

JANUARY 31, 2020

But it does prove that the patient has coronary disease and makes the probability that his chest pain is due to ACS very very high. It is proven better than angiography alone in stable angina , and also has been shown to improve decisions on stenting non-culprit lesions in ACS. It could be acute, though probably is not.

ED 52

ED Coronary ACS CAD 52

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. Just because you don't see hemodynamically significant CAD on angiogram does not mean it is not OMI. I could have told you this (and did tell you this) without an MRI.

Emergency Department 52

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

Dr. Smith's ECG Blog

JANUARY 1, 2013

A middle aged male with no h/o CAD presented with one week of crescendo exertional angina, and had chest pain at the time of the first ECG: Here is the patient's previous ECG: Here is the patient's presenting ED ECG: There is isolated ST depression in precordial leads, deeper in V2 - V4 than in V5 or V6. There is no ST elevation.

STEMI 52

STEMI ACS Coronary CAD 52

Dr. Smith's ECG Blog

NOVEMBER 26, 2018

The axiom of "type 1 (ACS, plaque rupture) STEMIs are not tachycardic unless they are in cardiogenic shock" is not applicable outside of sinus rhythm. This case represents the same physiologic event as OMI in terms of the result on the myocardium, therefore with identical ECG features, however there may not be ACS!

STEMI 52

STEMI ACS CAD OR 52

Dr. Smith's ECG Blog

AUGUST 9, 2019

But if they do present: The very common presentation of diffuse STD with reciprocal STE in aVR is NOT left main occlusion , though it might be due to sub total LM ACS, but is much more often due to non-ACS conditions, especially demand ischemia. Beware crescendo angina in patient with known CAD ST Elevation in aVR Case 7.

Coronary 52

Coronary STEMI ACS ALS 52

Dr. Smith's ECG Blog

JULY 11, 2019

These findings are very subtle but suspicious for LAD occlusion, as we have seen in many similar (but less difficult) cases on this blog: A man in his sixties with chest pain at midnight with undetectable troponin How long would you like to wait for your Occlusion MI to show a STEMI? He also had non-acute CAD of the RCA (50%) and LCX (50%).

STEMI 52

STEMI ACS CAD ED 52

Dr. Smith's ECG Blog

DECEMBER 13, 2019

Written by Pendell Meyers A man in his late 40s with several ACS risk factors presented with a chief complaint of chest pain. The cardiologists felt that the ECG did not represent ACS, and thought it was more likely pericarditis, so they did not take him to the cath lab. His first troponin T then resulted elevated at 0.19

E-9-1-1 52

E-9-1-1 ACS Coronary CAD 52

Dr. Smith's ECG Blog

JULY 31, 2018

She had zero CAD risk factors. Now you have ECG and troponin evidence of ischemia, AND ventricular dysrhythmia, which means this is NOT a stable ACS. hours of substernal chest pressure. It was non-radiating and without other associated symptoms except for nausea. Here was her ECG at time zero: What do you think?

Coronary 52

Coronary ACS STEMI OR 52

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

Although this is considered a "STEMI equivalent" and the ACC/AHA guidelines even approve of thrombolytics for ACS with this ECG, the usual criteria used to alert the cath lab team of an inbound Code STEMI are not met by this ECG. For instance: sepsis, bleeding, dehydration, hypoxia, and mild ACS.

Coronary 40

Coronary ACS ALS STEMI 40

Dr. Smith's ECG Blog

MAY 10, 2023

CAD-RADS category 1. --No CT Coronary angiogram is usually used to make ACS much less likely in the context of a patient who is ruled out for acute MI by troponins. Now, with elevated troponins, Wellens' syndrome is likely. A CT Coronary angiogram was ordered. Here are the results: --Minimally obstructive coronary artery disease. --LAD

Coronary 52

Coronary STEMI CAD OR 52

Dr. Smith's ECG Blog

SEPTEMBER 16, 2015

A middle-aged male with h/o CAD and stents presented with typical chest pressure. It is highly associated with proximal LAD occlusion or severe left main ACS and with bad outcomes. Here is his ECG: The resident was alarmed at the "ST elevation in III with reciprocal ST depression in aVL" Are you alarmed? This is a very common misread.

STEMI 40

STEMI CPR CAD Coronary 40

Dr. Smith's ECG Blog

MARCH 6, 2019

She did not receive any opioids (which would mask her pain without affecting any underlying ACS). She also had non-acute CAD of the left main (50%) and LCX (75%). By the time the patient arrived at our facility, she had received aspirin and nitroglycerin, and her pain had apparently completely resolved. They opened it.

STEMI 52

STEMI ALS ACS ICU 52

Dr. Smith's ECG Blog

OCTOBER 26, 2020

The patient was transferred immediately for angiogram which revealed no significant CAD, and no intervention was performed. Learning Points: The myocardium doesn't know the etiology of OMI (ACS, spasm, dissection, embolus, etc.), That said, ACS is by far the most common and treatable cause.

Coronary 40

Coronary Defibrillator ACS CAD 40

Dr. Smith's ECG Blog

DECEMBER 5, 2023

He did have a family history notable for early CAD. A final ECG was perfomed on hospital day 2: Persistent ST elevation in the inferior leads with slight reciprocal ST depression in aVL Teaching points - It is essential to consider ACS in all age groups. He denied drug or alcohol use. ng/mL (ULN 16,000 ng/L, mildly elevated CRP of 8.4

Coronary 121

Coronary CAD ACS ALS 121

Dr. Smith's ECG Blog

DECEMBER 31, 2024

But thankfully, when the clinical context is clearly and highly concerning for ongoing ischemia from ACS, this distinction doesn't matter much. The procedure was described as very complex due to severe multivessel CAD, but ultimately PCI was successfully performed to the ostial LCX. Pre-intervention.

Coronary 119

Coronary ACS STEMI CAD 119

Dr. Smith's ECG Blog

JANUARY 21, 2025

Negative trops and negative angiogram does not rule out coronary ischemia or ACS. It is a judgment call retrospectively, but to assume there is no ACS at presentation is very risky, especially in a patient with previously diagnosed severe CAD and poor LV function. It must be diagnosed with IVUS or Optical Coherence Tomography.

OR 62

OR Coronary STEMI ACS 62

Dr. Smith's ECG Blog

JANUARY 15, 2025

Case A 68 year old man with a medical history of hypertension, hyperlipidemia, and CAD with stent deployment in the RCA presented to the emergency department with chest pain. html ) Despite an undetectable troponin and three normal EKGs, the nature of the patients symptoms and his positive cardiac history warranted concern for ACS.

Coronary 68

Coronary ED CAD Paramedic 68