EMS 12-Lead

APRIL 21, 2022

There is appreciable STE aVR with near-global STD that appropriately maximizes in Leads II and V5, and thus suggesting a circumstance of generic, diffusely populated, circumferential subendocardial ischemia versus occlusive coronary thrombus. [1] It’s judicious, then, to arrange for coronary angiogram.

Coronary 130

Coronary ALS OR ACS 130

REBEL EM

JUNE 1, 2023

Article: Branch KHR et al. Indication for emergency invasive coronary angiography or had coronary angiography within 1 hour of arrival. Known obstructive coronary artery disease or known coronary stent. References: Branch KHR et al. appeared first on REBEL EM - Emergency Medicine Blog. Resus 2023.

Coronary 145

Coronary Defibrillator CPR ALS 145

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. Amsterdam et al. Alencar et al.

STEMI 121

STEMI Coronary ALS CAD 121

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

Thanks in part to rapid bedside diagnosis, the patient was able to avoid emergent coronary angiography. Consider the following: We become attuned to looking for acute coronary occlusion in patients who present with acute symptoms to the ED ( E mergency D epartment ). Figure-1: I've labeled the initial ECG in today's case.

E-9-1-1 127

E-9-1-1 Coronary STEMI ALS 127

Dr. Smith's ECG Blog

OCTOBER 3, 2024

Coronaries were clean. Not OMI with High Confidence Click here to sign up for Queen of Hearts Access We showed that the Queen of Hearts decreases false positive cath lab activations: 1) Published recently in Prehospital Emergency Care Baker PO et al. 2) To be presented at AHA conference in Chicago in 2 weeks: Sharkey SW et al.

E-9-1-1 123

E-9-1-1 Coronary ALS ED 123

REBEL EM

SEPTEMBER 14, 2023

Zeymer HT et al. References: Zeymer HT et al. PMID: 37634145 Post Peer Reviewed By: Anand Swaminathan, MD (Twitter/X: @EMSwami ) The post The ECLS-SHOCK Trial: ECPR in Infarct-Related Cardiogenic Shock appeared first on REBEL EM - Emergency Medicine Blog. bleeding, stroke, limb ischemia, and hemolysis). Control: 53.4%

Life Support 136

Life Support Coronary CPR ICU 136

EMOttawa

DECEMBER 18, 2023

Methodology: 3/5 Usefulness: 1/5 Georgiopoulos G, et al. 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

MAY 27, 2024

1] But there are multiple other abnormalities that make this ECG diagnostic of Occlusion MI, localized likely to the right coronary artery: 1. Systematic review and meta-analysis of diagnostic test accuracy of ST-segment elevation for acute coronary occlusion. Nikus et al. Kontos et al. Kontos et al. Bischof et al.

STEMI 122

STEMI Coronary ALS Emergency Department 122

Dr. Smith's ECG Blog

JULY 21, 2024

It shows a proximal LAD occlusion, in conjunction with a subtotally occluded LMCA ( Left Main Coronary Artery ). Upon contrast injection of the LMCA, the patient deteriorated, as the LMCA was severely diseased and flow to all coronary arteries ( LAD, LCx and RCA ) was compromised. He was taken immediately to the cath lab.

Defibrillator 131

Defibrillator Coronary ALS STEMI 131

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

JUNE 17, 2024

In fact, Kosuge et al. 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. “The

E-9-1-1 138

E-9-1-1 ACS Emergency Department Coronary 138

REBEL EM

SEPTEMBER 28, 2023

Paper: Van de Werf, F et al. STREAM-2: Half-Dose Tenecteplase or Primary Percutaneous Coronary Intervention in Older Patients With ST-Segment-Elevation Myocardial Infarction: A Randomized, Open-Label Trial. References: Van de Werf, F et al. PMID: 37439219 Armstrong P et al.

STEMI 138

STEMI Allergic Reaction Coronary Ambulance 138

Dr. Smith's ECG Blog

APRIL 22, 2024

A comparison of electrocardiographic changes during reperfusion of acute myocardial infarction by thrombolysis or percutaneous transluminal coronary angioplasty. Lemkes JS, et al. Total coronary occlusion, if very brief, may have minimal infarction and yet be very dangerous. Am Heart J. 2000;139:430–436. Eur Heart J [Internet].

Coronary 117

Coronary STEMI ED OR 117

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]. The original term " benign early repolarization" has fallen out of favor since the seminal paper by Haïssaguerre et al.

E-9-1-1 130

E-9-1-1 OR Coronary ACS 130

Dr. Smith's ECG Blog

JUNE 27, 2024

The proof of this is that only 5% of patients enrolled had acute coronary occlusion. Lemkes JS, Janssens GN, van der Hoeven NW, et al. Coronary Angiography after Cardiac Arrest without ST-Segment Elevation. We at Hennepin recently published this study Sharma et al. This study failed to do so. 5% vs. 58%!! 5% vs. 58%!!

Defibrillator 113

Defibrillator STEMI Coronary ALS 113

Dr. Smith's ECG Blog

MARCH 10, 2025

The latest is Langlois-Carbonneau et al. But like many similar studies, the study was small (one year at one centre with no indication of the incidence of acute coronary occlusion), and it used as the gold standard the final cardiologist interpretation of the ECG - not the patient outcome! But according to Langlois-Carbonneau et al.,

STEMI 89

STEMI OR Coronary Emergency Department 89

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). From there you can link to other great websites (including Dr. Smith's ECG Blog) that provide multiple case studies of both subtle and overt hyperkalemia. link] [1] Zachary et al. 2] Costanzo, L. Physiology.

ACS 130

ACS Paramedic Coronary ALS 130

Dr. Smith's ECG Blog

AUGUST 9, 2019

Post by Smith and Meyers Sam Ghali ( [link] ) just asked me (Smith): "Steve, do left main coronary artery *occlusions* (actual ones with transmural ischemia) have ST Depression or ST Elevation in aVR?" She had a proven 100% Left Main occlusion No ST shift in aVR This pattern of RBBB/LAFB was also the most common pattern in Fiol et al.

Coronary 52

Coronary STEMI ACS ALS 52

Dr. Smith's ECG Blog

MAY 23, 2023

I have here 38 cases of "Computer Normal" ECGs which were critically abnormal and the vast majority are missed acute coronary occlusions (Missed Acute OMI) and most were recognized by the physician. Of the Non-STEMI in our cohort, about 25% will actually have acute coronary occlusion. So this study is worthless and must be ignored.

STEMI 98

STEMI Coronary Paramedic 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. Serial ECGs enhance the diagnosis of acute coronary syndrome. Bigger et al. Sadowski ZP, Alexander JH, Skrabucha B, et al. Bigger JR Jr, Dresdale RJ, Heissenbuttel RH, et al. Leave it alone.

STEMI 107

STEMI Coronary Heart Attack ACS 107

REBEL EM

JANUARY 29, 2024

Click here for Direct Download of the Podcast Paper: Aykan AC et al. References: Jaff MR et al. PMID: 21422387 Wan S et al. PMID: 15262836 Sharifi M et al. PMID: 27422214 Wang C et al. PMID: 19741062 Kucher N et al. PMID: 24226805 Piazza G et al. PMID: 26315743 Tapson VF et al. CHEST 2010.

ALS 136

ALS ACS OR CPR 136

EMS 12-Lead

APRIL 28, 2022

In most cases, rather, the culprit is gross ischemia due to myocardial infarction, cardiomyopathy, or advanced coronary artery disease. Grauer on the Smith ECG Blog: [link] Take a deep dive into the management of TdP versus PVT with Dr. Smith: [link] [1] Callans, D. This finding might favor a diagnosis of ischemic-driven PVT.

E-9-1-1 130

E-9-1-1 ALS Coronary EMS 130

Dr. Smith's ECG Blog

JANUARY 1, 2024

His medical history includes hypertension, a decade-long battle with diabetes, ischemic heart disease, a coronary bypass graft surgery ten years ago, a diagnosis of congestive heart failure for the last five years, and a prior ICD implantation five years ago.

Coronary 112

Coronary EMR STEMI Emergency Department 112

Dr. Smith's ECG Blog

JANUARY 27, 2024

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 the patient had a transient acute coronary occlusion that spontaneously reperfused but is at risk for reocclusion. Deutch et al.

STEMI 117

STEMI Coronary ACS ED 117

Dr. Smith's ECG Blog

JULY 7, 2024

First trop was 7,000ng/L (normal 25% of ‘Non-STEMI’ patients with delayed angiography have the exact same pathology of acute coronary occlusion. The new ACC expert consensus explains that: “STEMI ECG criteria on a standard 12-lead ECG alone will miss a significant minority of patients who have acute coronary occlusion. Take home 1.

STEMI 66

STEMI Coronary ALS OR 66

Dr. Smith's ECG Blog

JUNE 14, 2024

He underwent coronary angiography which showed severe multivessel disease, and he agreed to proceed with workup for CABG. Additional review of ECG artifacts by Pérez-Riera et al ( Ann Noninvasic Electrocardiol 23:e12494, 2018 ) VT Artifact — by Knight et al: NEJM 341:1270-1274, 1999. The January 30, 2018 post — for PTA.

Defibrillator 81

Defibrillator ALS Coronary OR 81

Dr. Smith's ECG Blog

JUNE 21, 2023

Below is the version standardized by PM Cardio app Meyers interpretation: Findings are specific for posterior (and also likely inferior) wall transmural acute infarction, most likely due to acute coronary occlusion (OMI). Most OMI have a peak Troponin T over 1000 ng/L [reference: Baro R et al. Clinical Cardiology 2019.

STEMI 98

STEMI Coronary Defibrillator EMS 98

Dr. Smith's ECG Blog

SEPTEMBER 1, 2024

Abstract of QOH Retrospective Data by Willy Frick MD et al.

Coronary 52

Coronary ALS 52

EMS 12-Lead

APRIL 2, 2022

He reported a history of ischemic cardiomyopathy with coronary stent placement approximately 10 years prior, but could not recall the specific artery involved. Figure 2-1 The V1 / V2 leads were appropriately placed in this circumstance, and dedicated followers of the Smith ECG Blog will instantly recognize the problem at hand.

ALS 130

ALS STEMI Coronary OR 130

Dr. Smith's ECG Blog

JANUARY 5, 2024

Evidence regarding intervention to non-culprit plaques is mixed and beyond the scope of this blog post. Heitner et al. We have on many occasions in Dr. Smith's ECG Blog, highlighted the downside of indiscriminate use of morphine in patients who present with new ischemic CP ( C hest P ain ). DOI:10.1161/CIRCINTERVENTIONS.118.007305),

ACS 120

ACS ALS OR STEMI 120

Dr. Smith's ECG Blog

SEPTEMBER 5, 2024

A Short Comment on PIRP and T Waves: Oliva et al found a strong association of myocardial rupture with postinfarction regional pericarditis. Another possible cause of pseudonormalization of T waves mentioned many times on this blog is the pseudonormalization caused by re-occlusion of an infarct related reperfused coronary artery.

STEMI 109

STEMI Coronary OR ALS 109

Dr. Smith's ECG Blog

JANUARY 23, 2024

Even though the primary suspicion was not ischemic heart disease, a CT angiogram was performed, and it revealed normal coronary arteries. This ruled out coronary disease as the cause of conduction system disease. Most of the cases of AV block that we see in practice, are the result of underlying heart disease.

Coronary 107

Coronary OR Defibrillator ALS 107

Dr. Smith's ECG Blog

OCTOBER 18, 2023

Dr. Smith’s ECG Blog has published a growing list of over 40 cases of ECGs falsely labeled ‘normal’ by the computer which are diagnostic of Occlusion MI, and Smith et al. Smith’s ECG Blog has published a growing list of over 40 cases of ECGs falsely labeled ‘normal’ by the computer which are diagnostic of Occlusion MI, and Smith et al.

STEMI 119

STEMI Emergency Department Coronary OR 119

Dr. Smith's ECG Blog

JANUARY 6, 2024

Therefore the impulse must have originated somewhere lower in the atria, perhaps near the coronary sinus. In the 500+ Comments I have written on Dr. Smith's ECG Blog since becoming an Associate Editor in 2018 — I do not believe we have had a case of RA-LL lead reversal. Complete heart block is the state of the AV node.

ALS 111

ALS STEMI Coronary OR 111

Dr. Smith's ECG Blog

MAY 13, 2020

I have posted previous such cases, but in searching my own blog, I could not find them. The case I presented in My Comment to that March 9, 2020 post showed a patient with this pattern — who on cath had no more than minimal coronary disease. It would be a good topic for study. Smith adds to our knowledge of this syndrome.

Coronary 52

Coronary ACS EMS STEMI 52

Dr. Smith's ECG Blog

JULY 31, 2020

Their OMI Manifesto details how use of standard STEMI criteria results in an unacceptable level of inaccuracy, in which an estimated 25-30% of acute coronary occlusions are missed! The article by Aslanger, Smith et al that is featured above in today’s post has just been published. P.S.: Our September 3, 2020 post features Dr.

STEMI 52

STEMI Coronary EMR ALS 52

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 52

ACS Coronary STEMI Ambulance 52