ACS, Coronary and Document - Paramedicine Now

Dynamic OMI ECG. Negative trops and negative angiogram does not rule out coronary ischemia or ACS.

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

Compensatory enlargement was defined as being present when the total coronary arterial cross-sectional area at the stenotic site was greater than that at the proximal nonstenotic site. We documented that the majority of stenotic lesions had compensatory enlargement and thus exhibited remodeling. As was emphasized by Dr.

Coronary

Coronary ACS OR EMR

REBEL Cast Ep114: High Flow O2, Suspected ACS, and Mortality?

REBEL EM

MARCH 2, 2023

Background: Historically, we have treated acute coronary syndrome with supplemental oxygen regardless of the patient ’ s oxygen saturation. More recent evidence, however, demonstrates that too much oxygen could be harmful ( AVOID Trial ) by causing coronary vasoconstriction and increasing oxidative stress. Low O2 protocol: 3.1%

ACS

ACS Coronary STEMI Ambulance

Occlusion myocardial infarction is a clinical diagnosis

Dr. Smith's ECG Blog

DECEMBER 11, 2023

Triage documented a complaint of left shoulder pain. For the same reason, you should not delay coronary angiography because pain resolves with morphine. Smith : As Willy states, ACS with persistent symptoms is a guideline recommended indication for ＜2 hour angio (both ACC/AHA and ESC). This is shown below. Mukherjee, D.,

E-9-1-1

E-9-1-1 ACS Coronary STEMI

Another deadly triage ECG missed, and the waiting patient leaves before being seen. What is this nearly pathognomonic ECG?

Dr. Smith's ECG Blog

JUNE 17, 2024

showed that among patients with either acute coronary syndrome or acute pulmonary embolism and negative T waves in the precordial leads (V1-V4), that inverted T waves in leads III and V1 were present in only 1% of patients with acute coronary syndrome and 88% of patients with pulmonary embolism. In fact, Kosuge et al. Kosuge et al.

E-9-1-1

E-9-1-1 ACS Emergency Department Coronary

Acute OMI or "Benign" Early Repolarization?

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]. Cardiology consult note written around that time documents that "Pain improved with NTG, morphine in ED but still present."

E-9-1-1

E-9-1-1 OR Coronary ACS

How To Avoid Missing an Aortic Dissection

ACEP Now

JUNE 6, 2023

Notoriously elusive, with a high misdiagnosis rate, thoracic aortic dissection (AD) can mimic many conditions, including acute coronary syndrome (ACS, the most common), gastroesophageal reflux disease (GERD), stroke, and spinal-cord compression. ACS is the most common misdiagnosis and often leads to inappropriate anticoagulation.

ACS

ACS ALS ED OR

An elderly male with acute altered mental status and huge ST Elevation

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. Preliminary findings documented in the cath lab were “Anterior STEMI and no significant coronary artery disease.” (!!!) Both highly negative.

STEMI

STEMI Coronary Emergency Department OR

Judge for yourself the management of this patient with "NSTEMI, multivessel disease"

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

Ongoing pain noted throughout all documentation, but after nitro drip and prn morphine, "pain improved to 2/10." 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. Repeat trop 150 ng/L.

E-9-1-1

E-9-1-1 ACS STEMI Coronary

Case Report: a High-Voltage Victim

ACEP Now

MARCH 14, 2024

Current can be alternating current (AC) or direct current (DC) with AC typically more dangerous as it is more likely to cause tetanic contractions and increase contact time with the electrical source. 2,3,5 Except for laundry or electrical car outlets (240 V AC), all U.S. household outlets are rated at 120 V AC.

Operating Room

Operating Room ACS Critical Care Coronary

Three normal high sensitivity troponins over 4 hours with a "normal ECG"

Dr. Smith's ECG Blog

JANUARY 5, 2024

The documentation does not describe any additional details of the history. They also documented "Reproducible chest tenderness." Thus, these troponins are very concerning for ACS, and subsequent ones will probably be diagnostic of acute MI. The following ECG was obtained. ECG 1 What do you think? of the time.

ACS

ACS ALS OR STEMI

"The dye don't lie".except when it does. Angiogram Negative, or is it?

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. Another option would be to use Optical Coherence Tomography for Coronary Imaging ). Initial hscTnI was 10 ng/L (ref. <14).

OR

OR Coronary ACS EMS

Profound ST depression in II, III, aVF

Dr. Smith's ECG Blog

JULY 27, 2023

I did not think it was due to ACS, but we ordered an ED ECG immediately: What do you think? But in this case the clinical scenario is not right for acute ACS with OMI, and there is very high voltage, and the patient is very young, (though beware of young patients , even 29 year olds!! I was not worried for a coronary etiology.

Coronary

Coronary ACS Naloxone Plasma

46 year old with chest pain develops a wide complex rhythm -- see many examples

Dr. Smith's ECG Blog

AUGUST 9, 2024

He had no previously documented medical problems except polysubstance use. Serial ECGs enhance the diagnosis of acute coronary syndrome. 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.

STEMI

STEMI Coronary Heart Attack ACS

A fascinating electrophysiology case. What is this wide complex tachycardia, and how best to manage it?

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

Coronary ACS ED OR

REBEL Cast Ep123: Reduced-Dose Systemic Peripheral Alteplase in Massive PE?

REBEL EM

JANUARY 29, 2024

Click here for Direct Download of the Podcast Paper: Aykan AC et al. PMID: 23102885 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]. Clin Exp Emerg Med 2023. JACC Cardiovasc Interv 2018.

ALS

ALS ACS OR CPR

70-year-old with acute chest pain, STEMI negative: just an old infarct?

Dr. Smith's ECG Blog

APRIL 4, 2023

Fortunately, Dr. Cho was not looking for STEMI ECG criteria but for an acute coronary occlusion. As he documented, “This patient is experiencing chest pain consistent with an acute coronary syndrome. As cardiology documented, “possible STEMI. Start using the terms acute coronary occlusion and occlusion MI.

STEMI

STEMI Coronary OR ACS

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

Dr. Smith's ECG Blog

APRIL 14, 2023

It is easy to say this in retrospect, especially not being the one in charge of this overcrowded waiting room full of unseen patients, but an elderly patient with known CAD and ongoing ACS-sounding chest pain despite medical management with positive troponin is already an indication for emergent cath, regardless of the ECG!

CAD

CAD ACS STEMI Coronary

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

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

ED Coronary ACS CAD

Ischemic ST depression maximal in V1-V4 (vs. V5-V6), even if less than 0.1 millivolt, is specific for Occlusion Myocardial Infarction (vs. subendocardial non-occlusive ischemia)

Dr. Smith's ECG Blog

JUNE 27, 2021

If it is maximal in V1-V4, and the patient's presentation in consistent with ACS (as this certainly is), then it is DIAGNOSTIC of Occlusion with 90% specificity (We have an upcoming article that proves this). Angiogram: "ACS - Non ST Elevation Myocardial Infarction. This was not recognized. The patient was started on a nitro drip.

STEMI

STEMI ACS Coronary ED

Compare these two ECGs. Do either, neither, or both show anything important?

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

OR STEMI ACS Emergency Department

Are these Wellens' waves?

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

E-9-1-1 ACS ALS OR

Chest pain in a 30-something: Is it Normal variant STE or OMI? Get the prior ECG, and don't trust Point of Care troponin assays!

Dr. Smith's ECG Blog

OCTOBER 2, 2021

After rethinking the case, he remained concerned about ACS and subsequently performed a point-of-care ultrasound in order to evaluate for regional wall motion abnormality. We assume that at some point the patient's pain returned, but it is not documented, so exactly when this happened is uncertain. There is no age cut-off for ACS.

OR

OR ACS STEMI Coronary

Inferior Subtle ST elevation: straight ST segment, but also no reciprocal ST depression in aVL: which is more important?

Dr. Smith's ECG Blog

JUNE 28, 2019

For coronary anatomy, see here: [link] This is the post intervention ECG: All ST Elevation is gone (more proof that it was all a result of ischemia) Formal Echo: Normal estimated left ventricular ejection fraction - 55%. K EY P oints : This patient has known coronary disease. It was stented.

Coronary

Coronary ACS ED OR

AHA/NCS Statement on Critical Care Management of Post ROSC Patients

EMDocs

JANUARY 11, 2024

Early coronary angiography in post-CA patients with no ST-segment elevation on the presenting ECG may still be of benefit by potentially salvaging myocardium and decreasing the incidence of systolic heart failure in survivors (95.7%, 22/23). in patients with metabolic acidosis until acidosis can be otherwise treated (94.7%, 18/19).

Critical Care

Critical Care E-9-1-1 OR ICU

Management of STEMI (ST-Elevation Acute Myocardial Infarction)

ECG & Echo Learning

JANUARY 18, 2023

This page summarises the most current recommendations for the management of acute coronary syndromes with persistent ST-segment elevations (i.e III A Primary percutaneous coronary intervention strategy Management Recommendation Level of evidence Primary PCI of the infarct related artery (IRA) is indicated.

STEMI

STEMI Coronary OR Defibrillator

A "normal ECG" on a busy night

Dr. Smith's ECG Blog

OCTOBER 6, 2018

The patient was in his 50s with history of hypertension, diabetes, seizure disorder, and smoking, but no known coronary artery disease. No patient should have to be "lucky" by having a positive troponin to be taken seriously as a possible acute coronary occlusion. 418 of these 1788 (23%) had acute coronary occlusion.

STEMI

STEMI Coronary ALS OR

75 year old with 24 hours of chest pain, STEMI negative

Dr. Smith's ECG Blog

JUNE 8, 2023

According to the STEMI paradigm, the patient doesn’t have an acute coronary occlusion and doesn't need emergent reperfusion, so the paramedics can bring them to the ED for assessment, without involving cardiologists. Cardiology documented “late presentation STEMI but likely aborted given resolution of ST changes from EMS to hospital.”

STEMI

STEMI Coronary Paramedic ALS

Emergency Department Syncope Workup: After H and P, ECG is the Only Test Required for Every Patient.

Dr. Smith's ECG Blog

APRIL 8, 2015

Thus, if there is documented sinus bradycardia, and no suspicion of high grade AV block, at the time of the syncope, this is very useful. Negative predictors included dementia, pacemaker, coronary revascularization, and cerebrovascular disease. 2) Boston syncope rule: J Emerg Med. 2007 Oct; 33(3): 233–239. to 3.80).

Emergency Department

Emergency Department E-9-1-1 ED ALS

Paramedicine Now

Dynamic OMI ECG. Negative trops and negative angiogram does not rule out coronary ischemia or ACS.

REBEL Cast Ep114: High Flow O2, Suspected ACS, and Mortality?

Trending Sources

Occlusion myocardial infarction is a clinical diagnosis

Another deadly triage ECG missed, and the waiting patient leaves before being seen. What is this nearly pathognomonic ECG?

Acute OMI or "Benign" Early Repolarization?

How To Avoid Missing an Aortic Dissection

An elderly male with acute altered mental status and huge ST Elevation

Judge for yourself the management of this patient with "NSTEMI, multivessel disease"

Case Report: a High-Voltage Victim

Three normal high sensitivity troponins over 4 hours with a "normal ECG"

"The dye don't lie".except when it does. Angiogram Negative, or is it?

Profound ST depression in II, III, aVF

46 year old with chest pain develops a wide complex rhythm -- see many examples

A fascinating electrophysiology case. What is this wide complex tachycardia, and how best to manage it?

REBEL Cast Ep123: Reduced-Dose Systemic Peripheral Alteplase in Massive PE?

70-year-old with acute chest pain, STEMI negative: just an old infarct?

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

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

Ischemic ST depression maximal in V1-V4 (vs. V5-V6), even if less than 0.1 millivolt, is specific for Occlusion Myocardial Infarction (vs. subendocardial non-occlusive ischemia)

Compare these two ECGs. Do either, neither, or both show anything important?

Are these Wellens' waves?

Chest pain in a 30-something: Is it Normal variant STE or OMI? Get the prior ECG, and don't trust Point of Care troponin assays!

Inferior Subtle ST elevation: straight ST segment, but also no reciprocal ST depression in aVL: which is more important?

AHA/NCS Statement on Critical Care Management of Post ROSC Patients

Management of STEMI (ST-Elevation Acute Myocardial Infarction)

A "normal ECG" on a busy night

75 year old with 24 hours of chest pain, STEMI negative

Emergency Department Syncope Workup: After H and P, ECG is the Only Test Required for Every Patient.

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