Dr. Smith's ECG Blog

SEPTEMBER 9, 2024

The patient was thought to have low likelihood of ACS, and cardiology recommended repeat troponin, urine drug testing, and echocardiogram. At that point, cardiology elected to treat for ACS. NOTE: For review of 20 cases of "Swirl" vs Swirl "Look-Alikes" — Check out the October 15, 2022 post in Dr. Smith's ECG Blog.

OR 66

OR Coronary ACS EMS 66

Dr. Smith's ECG Blog

DECEMBER 22, 2023

The patient has active chest pain, so if these are abnormally large T-waves This link shows 13 blog posts of Posterior Reperfusion T-waves. Comment : ACS with persistent symptoms is a guideline recommended indication for ＜2 hour angio (both ACC/AHA and ESC). But it certainly shows no sign of OMI. Or does it?

ACS 103

ACS STEMI OR 103

Dr. Smith's ECG Blog

JUNE 5, 2024

As per my review of this subject ( Check out My Comment at the bottom of the page in the November 16, 2023 post in Dr. Smith's ECG Blog ) — the 3 most common Causes of ACS ( A cute C oronary S yndrome ) with a "negative" cath are: i ) Myocarditis; ii ) Takotsubo cardiomyopathy; and , iii ) MINOCA.

Coronary 106

Coronary ACS ALS OR 106

Dr. Smith's ECG Blog

OCTOBER 20, 2024

The ST segment changes are compatible with severe subendocardial ischemia which can be caused by type I MI from ACS or potentially from type II MI (non-obstructive coronary artery disease with supply/demand mismatch). sepsis, anemia, hypoxemia, severe hypotension etc., Unless some LMCA flow is restored he will not survive.

Coronary 125

Coronary ACS Emergency Department Defibrillator 125

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 107

STEMI ACS Coronary Emergency Department 107

Dr. Smith's ECG Blog

DECEMBER 5, 2023

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. While ACS may be less common in the pediatric population, it is important to consider risk factors that may make OMI more likely (e.g.,

Coronary 112

Coronary CAD ACS ALS 112

Dr. Smith's ECG Blog

DECEMBER 11, 2023

Smith : As Willy states, ACS with persistent symptoms is a guideline recommended indication for ＜2 hour angio (both ACC/AHA and ESC). Smith : As Willy states, ACS with persistent symptoms is a guideline recommended indication for ＜2 hour angio (both ACC/AHA and ESC). So I would be worried about inferior OMI. At midnight.

E-9-1-1 121

E-9-1-1 ACS Coronary STEMI 121

Dr. Smith's ECG Blog

JUNE 17, 2024

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. In this study, (quote) "negative T waves in leads III and V 1 were observed in only 1% of patients with ACS compared with 88% of patients with Acute PE (p less than 0.001).

E-9-1-1 136

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

Dr. Smith's ECG Blog

DECEMBER 12, 2022

You must understand this and the dynamic nature of ACS to provide excellent care for such patients. Here is the OMI progression of ECG findings for review: You can see that OMI ECG findings must "deflate" and pass through normal or near-normal in order to get to reperfusion findings. This is termed " pseudo-normalization."

OR 52

OR ACS STEMI Coronary 52

Dr. Smith's ECG Blog

MAY 3, 2024

RBBB + LAFB in the setting of ACS is very bad. Some patients have baseline RBBB with LAFB, but in patients with likely ACS, these are associated with severe infarction with cardiac arrest, cardiogenic shock or impending shock. Patients with ACS and RBBB/LAFB usually have a left main vs. proximal LAD. There is STE in aVR.

ACS 113

ACS ED Coronary EMS 113

Dr. Smith's ECG Blog

NOVEMBER 1, 2022

He had been smoking an opiate and suddenly collapsed. He was ventilated with BVM on arrival. He awoke with naloxone. This EKG was recorded as part of a standing order for critical care. He denied any CP or SOB. An EKG was repeated at 5 minutes The T-wave is less hyperacute. Maybe there is some spontaneous reperfusion? It does not radiate.

Overdose 52

Overdose OR Coronary ACS 52

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

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). ACE inhibitors, or potassium-sparing diuretics), are particularly susceptible. In the case of ACS, the ECG can rapidly change from this. Past medical history included HTN, HLD, and MI 10 years prior.

ACS 130

ACS Paramedic Coronary ALS 130

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 105

ICU ALS ACS EMS 105

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 122

CAD STEMI Coronary ACS 122

Dr. Smith's ECG Blog

NOVEMBER 8, 2024

However, due to the nature of the symptoms, the patient was treated for ACS and admitted to the hospital. Smith’s ECG Blog — the LA ( L eft A rm ) can be quickly identified as the “ culprit ” extremity because baseline artifact is maximal in leads I, III and aVL — present but less in leads aVR and aVF — and not present at all in lead II.

ACS 78

ACS Coronary STEMI OR 78

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 111

STEMI ACS Coronary OR 111

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 91

Coronary CAD ACS OR 91

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. 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. Potassium was normal.

STEMI 86

STEMI ACS OR ALS 86

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

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. or basilar ischemia. EKG on arrival to the ED is shown below: What do you think? However, T waves do not appear to be hyperacute or hyperkalemic. Version 2 = 0.0272.

STEMI 97

STEMI Coronary Emergency Department OR 97

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

REBEL EM

NOVEMBER 6, 2024

Elbow Dislocation Definition: Disarticulation of the proximal radius & ulna bones from the humerus Epidemiology: Incidence Second most common joint dislocation (after shoulder) in adults Most commonly dislocated joint in children Accounts for 10-25% of all injuries to the elbow ( Cohen 1998 ) Posterolateral is the most common type of dislocation (..)

E-9-1-1 59

E-9-1-1 ACS OR Emergency Department 59

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. Fortunately, that is exactly what happened.

E-9-1-1 118

E-9-1-1 Coronary ACS BLS 118

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. It is not yet available, but this is your way to get on the list. link] Case continued She arrived in the ED and here is the first ED ECG.

Coronary 101

Coronary E-9-1-1 STEMI ACS 101

EMS 12-Lead

APRIL 21, 2022

Dedicated followers of the Smith ECG Blog know that the STD of true subendocardial ischemia does not localize, yet some of the examples listed below demonstrate the opposite, and were subsequently labeled “diffuse ischemia” or “generic subendocardial changes” as a diagnosis of convenience. Here is the time-zero ECG (0939 hours).

Coronary 130

Coronary ALS OR 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? Large volume fluid resuscitation was undertaken.

ACS 52

ACS STEMI OR Critical Care 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. No wall motion abnormality.

ACS 52

ACS STEMI OR 52

Dr. Smith's ECG Blog

NOVEMBER 10, 2024

The ECG was transmitted to the Emergency Medicine physician who recognized inferior and posterior OMI findings, and confirmed that the patient has potential ACS symptoms. The T waves in V5-6 are likely also hyperacute. The cath lab was activated despite lack of STEMI criteria, around 2 am in the morning. Just not yet. So WHY wait? As per Drs.

STEMI 81

STEMI OR ED EMS 81

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

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. A diagnosis of "reflux" or "GERD" is never supportable without a troponin rule out. His angiogram is shown below.

ACS 106

ACS ALS OR STEMI 106

Dr. Smith's ECG Blog

NOVEMBER 14, 2023

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 ). The emergency physician was skeptical and believed the ECG to be a mimic, a false positive.

E-9-1-1 107

E-9-1-1 Coronary EMS ED 107

REBEL EM

NOVEMBER 30, 2023

Article: Vaeli Zadeh A, Wong A, Crawford AC, Collado E, Larned JM. References: Vaeli Zadeh A, Wong A, Crawford AC, Collado E, Larned JM. Rezaie, MD (Twitter/X: @srrezaie ) The post Congestive Heart Failure and Sepsis: A Closer Look at Fluid Management appeared first on REBEL EM - Emergency Medicine Blog. 2.89, p = 0.01.

E-9-1-1 122

E-9-1-1 ALS ACS ICU 122

REBEL EM

JANUARY 29, 2024

Click here for Direct Download of the Podcast Paper: Aykan AC et al. Because the lungs receive 100% of cardiac output, it has been hypothesized that a lower dose of thrombolytic therapy may still be effective with a better safety profile [3][4]. REBEL Cast Ep123: Reduced-Dose Systemic Peripheral Alteplase in Massive PE?

ALS 137

ALS ACS OR CPR 137

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 98

Coronary ACS ED OR 98

Dr. Smith's ECG Blog

AUGUST 9, 2024

This has been discussed many times before on this blog. In-depth discussion is beyond the scope of this blog. 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. Leave it alone.

STEMI 84

STEMI Coronary Heart Attack ACS 84

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 117

STEMI Coronary ALS CAD 117