ACS, CAD and ED - Paramedicine Now

Wide Complex Tachycardia

EMS 12-Lead

AUGUST 18, 2024

David Didlake EMT-P, RN, ACNP @DidlakeDW An adult male self-presented to the ED with palpitations and the following ECG. He denied any known history of CAD, but did report ASCVD risk factors to include HTN, HLD, and DM. The patient was very uncomfortable, dyspneic, and displayed an SpO2 90% on RA.

CAD

CAD EMT EMT ACS

Elder Male with Syncope

EMS 12-Lead

APRIL 9, 2024

At the time of ED arrival he was alert, oriented, and verbalizing only a headache with a normalized BP. The ED activated trauma services, and a 12 Lead ECG was captured. This was deemed “non-specific” by the ED physicians. Thus, the ED admission ECG changes cannot be blamed on LVH. The fall was not a mechanical etiology.

Coronary

Coronary ACS CAD ED

An undergraduate who is an EKG tech sees something. The computer calls it completely normal. How about the physicians?

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

CAD STEMI Coronary ACS

SGEM#370: Listen to your Heart (Score)…MACE Incidence in Non-Low Risk Patients with known Coronary Artery Disease

The Skeptics' Guide to EM

JULY 2, 2022

Case: You are working a shift in your local community emergency department (ED) when a 47-year-old male presents with chest pain. Background: Chest pain is one of the most common presentations to the ED. In prior decades nearly all patients presenting to EDs with chest pain were admitted to hospital. AEM June 2022.

Coronary

Coronary Heart Attack ACS CAD

OMI in a pediatric patient? Teenagers do get acute coronary occlusion, so don't automatically dismiss the idea.

Dr. Smith's ECG Blog

DECEMBER 5, 2023

He did have a family history notable for early CAD. An ECG was perfomed on arrival to our ED: NSR with ST elevation II,III, aVF with reciprocal depression in aVL Would you refer this pediatric patient for emergent PCI? Morrissey and Bracey — regarding consideration of ACS ( A cute C oronary S yndrome ) in a younger patient.

Coronary

Coronary CAD ACS ALS

Formula Utilization

EMS 12-Lead

JUNE 20, 2022

Moreover, he had no pertinent medical history to report in terms of CAD, HTN, HLD, or DM, for example. 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. Here is the final ECG just prior to ED transfer.

ACS

ACS Coronary STEMI CAD

An 80 year old woman with Left Bundle Branch Block (LBBB) and pleuritic chest pain

Dr. Smith's ECG Blog

MARCH 19, 2024

The patient presented to an outside hospital An 80yo female per triage “patient presents with chest pain, also hurts to breathe” PMH: CAD, s/p stent placement, CHF, atrial fibrillation, pacemaker (placed 1 month earlier), LBBB. This case was sent by Amandeep (Deep) Singh at Highland Hospital, part of Alameda Health System.

CAD

CAD STEMI ACS ALS

Critical Left Main

EMS 12-Lead

JULY 24, 2023

David Didlake Acute Care Nurse Practitioner Firefighter / Paramedic (ret) @DidlakeDW Expert commentary and peer review by Dr. Steve Smith [link] @smithECGBlog A 57 y/o Female with PMHx HTN, HLD, DM, and current use of tobacco products, presented to the ED with chest discomfort. A 12 Lead ECG was captured on her arrival.

Coronary

Coronary ACS CAD ED

A man in his 60s with acute chest pain and high voltage

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

CAD ACS STEMI Coronary

See this "NSTEMI" go unrecognized for what it really is, how it progresses, and what happens

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

ACS Coronary ALS CAD

Dark Side of the Moon

EMS 12-Lead

APRIL 8, 2022

Furthermore, there was no family history of early CAD, MI, or sudden cardiac death. 1] Here is the admitting ED ECG after cancellation of Code STEMI. The patient continued to verbalize cessation of symptoms while in the ED. He reported to EMS a medical history of GERD only. However, in this context (i.e.

STEMI

STEMI ALS Coronary CAD

Watch what happens when you teach others how to find OMI

Dr. Smith's ECG Blog

MARCH 20, 2023

Case "Male, 43yo, come to ED with Epigastric Pain started 3 hours ago. 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. Risk Factors: High Cholesterol.

STEMI

STEMI ACS CAD ED

A 40 year old man with chest pain since last night

Dr. Smith's ECG Blog

JULY 11, 2019

Cardiology was called and the patient was taken for urgent catheterization with the time from ED arrival to cath about 1 hour and 45 minutes. He also had non-acute CAD of the RCA (50%) and LCX (50%). I focus my att ention on the interpretation of the initial ED tracing ( = E CG # 1 in Figure-1 ).

STEMI

STEMI ACS CAD ED

"Pericarditis" strikes again

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

E-9-1-1 ACS Coronary CAD

PseudoSTEMI and True ST elevation in Right Bundle Branch Block (RBBB). Don't miss case 4 at the bottom.

Dr. Smith's ECG Blog

SEPTEMBER 16, 2015

A middle-aged male with h/o CAD and stents presented with typical chest pressure. The patient arrived in the ED and had this ECG recorded: Interpretation? It is highly associated with proximal LAD occlusion or severe left main ACS and with bad outcomes. This is a very common misread. The trick is to find the end of the QRS.

STEMI

STEMI CPR CAD Coronary

An athletic 30-something woman with acute substernal chest pressure

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. The 1st “lesson” is, “All bets are off” — when an adult of any age presents to the ED with new-onset chest discomfort. hours of substernal chest pressure.

Coronary

Coronary ACS STEMI OR

H/o MI and stents with brief angina has this ED ECG. And what is Fractional Flow Reserve?

Dr. Smith's ECG Blog

JANUARY 31, 2020

A middle-aged man complained of 15 minutes of classic angina that resolved upon arrival to the ED. 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. Figure-1: The initial ECG that was done in the ED ( See text ).

ED

ED Coronary ACS CAD

A man in his 30s with cardiac arrest and STE on the post-ROSC ECG

Dr. Smith's ECG Blog

OCTOBER 10, 2022

He reportedly told his family "I think I'm having a heart attack", then they immediately drove him to the ED, and he was able to ambulate into the triage area before he collapsed and became unresponsive. CPR was initiated immediately. It was reportedly a PEA arrest; there was no recorded V Fib and no defibrillation.

ACS

ACS CPR CAD Heart Attack

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting."

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

Emergency Department E-9-1-1 Coronary STEMI

A 30-something woman with intermittent CP, a HEART score of 2 and a Negative CT Coronary Angiogram on the same day

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

Coronary STEMI CAD OR

Diffuse Subendocardial Ischemia on the ECG. Left main? 3-vessel disease? No!

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

The patient was brought directly to the cardiac catheterization lab for PCI, bypassing the ED. 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.

Coronary

Coronary ACS ALS STEMI

What will you do for this patient transferred to you who is now asymptomatic?

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 was asymptomatic at the time of this ECG recorded on arrival to our ED: What do you think? She also had non-acute CAD of the left main (50%) and LCX (75%). What will you do for this asymptomatic patient??? They opened it.

STEMI

STEMI ALS ACS OR

How does Acute Total Left Main Coronary occlusion present on the ECG?

Dr. Smith's ECG Blog

AUGUST 9, 2019

Smith and Meyers answer: First , LM occlusion is uncommon in the ED because most of these die before they can get a 12-lead recorded. Beware crescendo angina in patient with known CAD ST Elevation in aVR Case 7. Only 28% of patients had ACS of any vessel, and, of those patients, the LM was the culprit in just 49% (14% of all cases).(56)

Coronary

Coronary STEMI ACS ALS

Paramedicine Now

Wide Complex Tachycardia

Elder Male with Syncope

Trending Sources

An undergraduate who is an EKG tech sees something. The computer calls it completely normal. How about the physicians?

SGEM#370: Listen to your Heart (Score)…MACE Incidence in Non-Low Risk Patients with known Coronary Artery Disease

OMI in a pediatric patient? Teenagers do get acute coronary occlusion, so don't automatically dismiss the idea.

Formula Utilization

An 80 year old woman with Left Bundle Branch Block (LBBB) and pleuritic chest pain

Critical Left Main

A man in his 60s with acute chest pain and high voltage

See this "NSTEMI" go unrecognized for what it really is, how it progresses, and what happens

Dark Side of the Moon

Watch what happens when you teach others how to find OMI

A 40 year old man with chest pain since last night

"Pericarditis" strikes again

PseudoSTEMI and True ST elevation in Right Bundle Branch Block (RBBB). Don't miss case 4 at the bottom.

An athletic 30-something woman with acute substernal chest pressure

H/o MI and stents with brief angina has this ED ECG. And what is Fractional Flow Reserve?

A man in his 30s with cardiac arrest and STE on the post-ROSC ECG

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting."

A 30-something woman with intermittent CP, a HEART score of 2 and a Negative CT Coronary Angiogram on the same day

Diffuse Subendocardial Ischemia on the ECG. Left main? 3-vessel disease? No!

What will you do for this patient transferred to you who is now asymptomatic?

How does Acute Total Left Main Coronary occlusion present on the ECG?

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