Dr. Smith's ECG Blog

JUNE 5, 2024

Why Was Cardiac Cath Negative for Coronary Disease? As noted by Dr. Nossen — this patient qualified as MINOCA ( M yocardial I nfarction with N on- O bstructive C oronary A rteries ) — since troponin was positive on his 2nd admission, yet there was no evidence of obstructive coronary disease on cath.

Coronary 122

Coronary ACS ALS OR 122

Dr. Smith's ECG Blog

JULY 25, 2024

But cardiac arrest is a period of near zero flow in the coronary arteries and causes SEVERE ischemia. Then assume there is ACS. Smith's ECG Blog ( See My Comment in the March 1, 2023 post) — DSI does not indicate acute coronary occlusion! It also does not uniformly indicate severe coronary disease.

Defibrillator 124

Defibrillator Coronary Epinephrine ACS 124

EMS 12-Lead

AUGUST 18, 2024

I interpreted the ECG as VT with two primary etiological possibilities: 1. Abrupt plaque ulceration of Type 1 ACS leading to VT. Ultimately the patient went to Cath and was found to have multi-vessel obstructive coronary disease with an acute LCX culprit vessel, which was stented.

CAD 147

CAD EMT EMT ACS 147

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

EMS 12-Lead

JULY 24, 2023

Category 1 : Sudden narrowing of a coronary artery due to ACS (plaque rupture with thrombosis and/or downstream showering of platelet-fibrin aggregates. It’s judicious, then, to arrange for coronary angiogram. Supply-demand mismatch (non-occlusive coronary disease, or exacerbation of preexisting flow insufficiency) a.

Coronary 130

Coronary ACS CAD ED 130

The Skeptics' Guide to EM

SEPTEMBER 11, 2021

Acute coronary syndrome (ACS) is responsible for the majority (60%) of all OHCAs in patients. Emergency coronary angiography is reasonable for select (eg, electrically or hemodynamically unstable) adult patients who are comatose after OHCA of suspected cardiac origin but without ST elevation on ECG (Class IIa, LOE B-NR).

EMR 130

EMR Coronary Defibrillator Life Support 130

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." We don't know if he had a stress test, a CT Coronary angiogram, or they just decided to do an angiogram.

ACS 52

ACS Coronary OR 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). 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. 2] Costanzo, L.

ACS 130

ACS Paramedic Coronary ALS 130

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

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. An angiogram showed no acute coronary lesions. Are the lungs clear? The K returned at 6.9

ACS 52

ACS STEMI OR Critical Care 52

Dr. Smith's ECG Blog

MAY 20, 2024

The scan also showed “scattered coronary artery plaques”. __ Smith comment 1 : the appropriate management at this point is to lower the blood pressure (lower afterload, which increases myocardial oxygen demand). They too have dense white masses consistent with coronary atherosclerosis. The blue circle shows the LCx.

CAD 125

CAD STEMI Coronary ACS 125

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. The next day, and angiogram showed normal coronary arteries. Now there is much less ST segment deviation, less elevation and less depression.

ACS 52

ACS Defibrillator Epinephrine STEMI 52

EMS 12-Lead

JULY 30, 2023

She was known to have a history of poorly controlled COPD, AFib, and multivessel coronary disease. This should prompt immediate investigation into supply-demand mismatching, or ACS. David Didlake, FF/EMT-P, AG-ACNP @DidlakeDW An elder female presented to the ED with worsening shortness of breath. A 12 Lead ECG was captured.

EMT 130

EMT EMT ACS Coronary 130

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 27, 2023

Note that as many as 7% of patients with acute coronary syndrome have chest pain reproducible on palpation [Lee, Solomon]. which reduces the pre-test probability of acute coronary syndrome by less than 30% [McGee]. Chest pain reproducible on palpation does not rule out acute coronary syndrome. Guagliumi, G., Iwaoka, R.

E-9-1-1 130

E-9-1-1 OR Coronary ACS 130

Dr. Smith's ECG Blog

SEPTEMBER 20, 2011

Now, it is true that shortly after a non-ACS cardiac arrest, there can be transient diffuse ST depression, but not ST elevation in a coronary distribution, and there should not be a wall motion abnormality. There was faint filling of the distal branches of the RCA by collaterals from the left coronary system.

Coronary 52

Coronary STEMI ACS ED 52

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-9-1-1 127

E-9-1-1 Coronary ACS BLS 127

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

Dr. Smith's ECG Blog

APRIL 9, 2024

ACS then becomes less likely. Before the lab values returned this patient had a n emergent coronary CT angiogram done that ruled out CAD. A false positive cath lab activation is also off course acceptable for this diagnosis if you cannot get an emergent coronary CT angiogram. There are no coronary stenoses.

Coronary 108

Coronary CAD ACS OR 108

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. A Bayesian approach to acute coronary occlusion.

STEMI 121

STEMI Coronary ALS CAD 121

Dr. Smith's ECG Blog

APRIL 2, 2024

I was there and said, "No, I think this is all due to severe chronic cardiomyopathy and cardiac arrest due to primary ventricular fibrillation, not due to ACS." _ Why did I say that? For this reason we did not believe this was an acute coronary event and did not activate the cath lab. So we should activate the cath lab, right?

Defibrillator 132

Defibrillator Coronary Epinephrine CPR 132

EMDocs

JANUARY 8, 2024

Emergent coronary angiography is not recommended over a delayed or selective strategy in patients with ROSC after cardiac arrest in the absence of ST-segment elevation, shock, electrical instability, signs of significant myocardial damage, and ongoing ischemia (Level 3: no benefit). COR 2a, LOE B-R. COR 1, LOE B-NR. COR 2a, LOE B-NR.

Epinephrine 98

Epinephrine Defibrillator Coronary CPR 98

Dr. Smith's ECG Blog

MAY 10, 2023

A CT Coronary angiogram was ordered. Here are the results: --Minimally obstructive coronary artery disease. --LAD Although a lesion is not visible anatomically on this CT scan, coronary catheter angiography could be considered based on Cardiology evaluation." A repeat troponin returned at 0.45 CAD-RADS category 1. --No

Coronary 52

Coronary STEMI CAD OR 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. So this study is actually worthless.

STEMI 117

STEMI Coronary ACS ED 117

Dr. Smith's ECG Blog

AUGUST 11, 2024

Despite many ECG signs of OMI being missed the door-to-cath time was still fast, because all the healthcare providers were focused on the pathology of acute coronary occlusion and not were distracted by the lack of STEMI criteria. Start using the terms acute coronary occlusion and occlusion MI.

STEMI 100

STEMI Paramedic Coronary EMS 100

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

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

The Skeptics' Guide to EM

MAY 28, 2022

The SGEM bottom line was there is moderate level of evidence that ACS can be excluded in adult patients with recurrent, low-risk chest pain using a single hs-troponin below a validated threshold without further diagnostic testing in patients who have a CCTA within the past two years showing no coronary stenosis.

Emergency Department 100

Emergency Department ACS ALS Coronary 100

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 82

ACS Coronary ALS CAD 82

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. Association of intravenous morphine use and outcomes in acute coronary syndromes: Results from the CRUSADE Quality Improvement Initiative.

E-9-1-1 78

E-9-1-1 ACS STEMI Coronary 78

Dr. Smith's ECG Blog

MARCH 1, 2023

This pattern occurs regardless of whether the cause is ACS (decreased supply) or any other cause of decreased supply or increased demand. You must understand that this pattern does not differentiate ACS from other causes of supply/demand mismatch.

Allergic Reaction 52

Allergic Reaction E-9-1-1 Epinephrine Coronary 52

Dr. Smith's ECG Blog

OCTOBER 24, 2019

The biphasic T wave is consistent with recent reperfusion of an occluded coronary artery supplying the inferior region. Here’s the angiogram of the RCA : No thrombus or plaque rupture in the RCA (or any coronary artery) was found. This MI wasn’t caused by a ruptured plaque of CAD - it was a coronary artery dissection of the RCA.

Coronary 52

Coronary CAD ACS STEMI 52

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 96

STEMI Coronary ACS OR 96

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., Click to enlarge.)

STEMI 52

STEMI Coronary ACS Critical Care 52

Dr. Smith's ECG Blog

APRIL 24, 2015

Does this patient have ACS? He did not have ACS. Ventricular fibrillation is not only caused by acute coronary syndrome. The remainder were due to other etiologies, (including NonSTEMI ACS). But approximately 50% were due to non-ACS etiologies. The patient was cardioverted. Should he necessarily go to the cath lab?

Defibrillator 52

Defibrillator ACS CAD STEMI 52

Dr. Smith's ECG Blog

MARCH 13, 2024

Distilling this case into its most salient components, a man with multiple risk factors for coronary disease is presenting with several days of chest pain and markedly elevated troponin with no other reason to explain the lab abnormality ( e.g. sepsis). The patient has ACS by history, active pain, and an elevated troponin.

Coronary 108

Coronary ACS Emergency Management Emergency Manager 108

Dr. Smith's ECG Blog

DECEMBER 14, 2016

We could not rule out acute epicardial coronary (large artery) occlusion. Learning Point Acute coronary occlusion may occur with no ECG findings whatsoever. A subgroup of patients with refractory ischemic symptoms or hemodynamic or rhythm instability are candidates for urgent coronary angiography and revascularization."

ACS 52

ACS STEMI Coronary OR 52