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-9-1-1 123

E-9-1-1 Coronary ACS BLS 123

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

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. STEMI criteria, and automated interpretations based on it, will miss acute coronary occlusion. Take home 1.

STEMI 63

STEMI Coronary Paramedic ALS 63

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 70

OR Coronary ACS EMS 70

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 87

ACS Coronary ALS CAD 87

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 82

E-9-1-1 ACS STEMI Coronary 82

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 52

Coronary ACS Naloxone Plasma 52

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

More past history: hypertension, tobacco use, coronary artery disease with two vessel PCI to the right coronary artery and circumflex artery several years prior. This is diagnostic of ACS; it appears to be a reperfused acute inferior OMI. It is unknown when this pain recurred and became constant.

Defibrillator 134

Defibrillator Coronary STEMI CPR 134

Dr. Smith's ECG Blog

SEPTEMBER 7, 2024

No wall motion abnormality This shows that significant ACS can have ZERO WMA!! A comparison of electrocardiographic changes during reperfusion of acute myocardial infarction by thrombolysis or percutaneous transluminal coronary angioplasty. And dynamic ST-T wave changes between ECG #1 and ECG #2 confirm an acute event in progress.

STEMI 116

STEMI ACS Critical Care OR 116

Dr. Smith's ECG Blog

NOVEMBER 14, 2023

We who know ischemic ECGs know that really when T-wave inversion is specific for coronary thrombosis that it indicates reperfusion of the artery, not active occlusion. that is, show a pattern of labile ST-T wave changes not due to an acute coronary event. I personally can hardly wait for that future version!

E-9-1-1 111

E-9-1-1 Coronary EMS ED 111

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 105

STEMI Coronary ACS ED 105

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 52

CAD ACS STEMI Coronary 52

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. We know that even high-sensitivity troponin may not exceed the "normal" range for a period of hours in certain patients with acute coronary occlusion. The troponin is trapped in the myocardium that is not being perfused.

ACS 110

ACS ALS OR STEMI 110

Dr. Smith's ECG Blog

JANUARY 23, 2023

Recall that, in the setting of ACS symptoms, ST depression that are maximal in leads V1-V4 (as opposed to V5 and V6) not attributable to an abnormal QRS complex is specific for OMI. The most recent event had occurred just before being triaged. This pattern is recognizable by the ST depressions maximal in lead V4.

ACS 52

ACS Coronary Defibrillator STEMI 52

Dr. Smith's ECG Blog

JULY 31, 2018

Subsequent events: Later, before being taken to her room, the 2nd troponin returned at 1.01 Now you have ECG and troponin evidence of ischemia, AND ventricular dysrhythmia, which means this is NOT a stable ACS. What is Spontaneous Coronary Artery Dissection (SCAD)? She felt more comfortable being admitted.

Coronary 52

Coronary ACS STEMI OR 52

Dr. Smith's ECG Blog

APRIL 8, 2022

The ECG is diagnostic for acute transmural infarction of the anterior and lateral walls, with LAD OMI being the most likely cause (which has various potential etiologies for the actual cause of the acute coronary artery occlusion, the most common of which is of course type 1 ACS, plaque rupture with thrombotic occlusion).

STEMI 52

STEMI Coronary ACS ED 52

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. Start using the terms acute coronary occlusion and occlusion MI. That’s exactly what happened in this case.

STEMI 52

STEMI Coronary OR ACS 52

Dr. Smith's ECG Blog

DECEMBER 26, 2020

No obvious adverse events were attributed to the thrombolytics. Second, the increased demand created by extreme tachycardia may exceed the ability of the coronary arteries to supply sufficient blood (due to preexisting three vessel or left main disease, with or without ACS). There was again no intracranial hemorrhage.

STEMI 52

STEMI ACS Coronary Emergency Department 52

Dr. Smith's ECG Blog

FEBRUARY 6, 2023

Corroborating this is the subtle ST depression in V2-V3 which is inappropriate for the normal QRS complex, and in the context of ACS, we have shown this is quite specific for posterior OMI. In the context of ACS, ST depression maximal in V1-V4 (rather than V5-V6) not due to a QRS abnormality is specific for posterior OMI.

ACS 52

ACS EMS STEMI Coronary 52

Dr. Smith's ECG Blog

SEPTEMBER 24, 2023

I showed this to some of my colleagues and they were not able to confidently say that this is an acute coronary occlusion. Guidelines say that if a patient has ACS but refractory pain, the patient should go emergently to the cath lab. Back to the case. Initial troponin I returned elevated at 84 ng/L (ref value <34 ng/L).

STEMI 90

STEMI Coronary ACS OR 90

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. They were less likely to have STEMI on ECG, and more likely to be initially diagnosed as non-ACS. Dialysis patients have a high rate of ACS without chest pain and high rate of delayed diagnosis and delayed reperfusion 2.

STEMI 86

STEMI ACS OR ALS 86

Dr. Smith's ECG Blog

JUNE 27, 2021

The patient has heart failure as a result of this event. 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.

STEMI 52

STEMI ACS Coronary ED 52

Dr. Smith's ECG Blog

OCTOBER 24, 2018

The patient would not have been diagnosed with acute coronary syndrome and would not have had an angiogram, would have been discharged (or perhaps had a stress test, which would be negative), and would be at great risk of another event, possibly resulting in death or heart failure. Imagine if you had only recorded the 2nd ECG.

E-9-1-1 52

E-9-1-1 STEMI ACS Coronary 52

Dr. Smith's ECG Blog

NOVEMBER 1, 2022

The 50-something patient with history of coronary stenting and slightly reduced LV ejection fraction. which would suggest reduced rates of major adverse cardiac events with coronary artery bypass grafting." On the other hand, stable EKG over an hour in the setting of ongoing acute coronary syndrome is again unusual.

Overdose 52

Overdose OR Coronary ACS 52

Dr. Smith's ECG Blog

OCTOBER 26, 2020

All of these episodes occurred without any symptoms reported from the patient, even after pointed questioning during the telemetry events. This event similarly starts with a progression from normal to enlarging T waves with simultaneously increasing STE. Coronary spasm causing massive current of injury with shark fin ECG.

Coronary 52

Coronary Defibrillator ACS CAD 52

Dr. Smith's ECG Blog

MARCH 12, 2018

Wellens pattern is a term which refers to coronary reperfusion morphology in the anterior leads) The best answer is because the entire gestalt of the ECG shows acute right heart strain instead, and just does not look like Wellens after you've seen Wellens hundreds of times. looked at consecutive patients with PE, ACS, or neither.

ACS 52

ACS Coronary ALS ICU 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

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 52

Coronary ACS ED OR 52

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

FEBRUARY 6, 2020

Whenever the only presenting symptom is syncope, without any other symptom, I am very skeptical that coronary occlusion (OMI) is the etiology. Abdominal pain can of course be a symptom of ACS, but it was brief and seemed to have resulted in a vasovagal event. It is certainly possible, but the pretest probability is very low.

ACS 52

ACS ED Coronary STEMI 52

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 40

STEMI Coronary OR Defibrillator 40

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

NOVEMBER 12, 2020

And so it is wise to look at the coronary arteries. This ECG certainly looks like myocarditis, and was due to myocarditis, but missing acute coronary occlusion is not acceptable. In a series of 18 patients with COVID and ST elevation, 8 were diagnosed with STEMI, 6 of whom had an angiogram and it showed obstructive coronary disease.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

Dr. Smith's ECG Blog

DECEMBER 10, 2019

The pediatric team felt it might be ACS, but on review of his prior ECGs, it was thought to be really unchanged from the 2 prior and more consistent with myocarditis. But young people do have MI, due to anomalous coronary arteries, coronary artery dissection, Kawasaki dz, even atherosclerotic plaque rupture, and other etiologies.

E-9-1-1 52

E-9-1-1 Coronary OR ACS 52

EM Didactic

JANUARY 27, 2019

Myth 1 Absence of Classic Chest Pain obviates the need for ACS work up The absence of chest pain in no way excludes the diagnosis of ACS. Around 33-50% of the patients with ACS present to the hospital without chest pain. Close to 20% of patients diagnosed with acute MI present with symptoms other than chest pain.

ACS 52

ACS ALS Coronary Emergency Department 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. Takotsubo is a sudden event, not one with crescendo angina. Such cases are classified as MINOCA (Myocardial Infarction with Non-Obstructed Coronary Arteries).

Emergency Department 52

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

Dr. Smith's ECG Blog

JULY 11, 2019

This is a h igher - p revalence H istory for acute coronary disease. Meyers : This ECG was texted to me with no clinical information, and my response was: "That looks like a very subtle LAD OMI. By this, I mean that the onus is on us to rule out that even subtle ECG changes may be acute — rather than the other way around.

STEMI 52

STEMI ACS CAD ED 52