Dr. Smith's ECG Blog

OCTOBER 24, 2018

Therefore, this does not meet the definition of myocardial infarction ( 4th Universal Definition of MI ), which requires at least one troponin above the 99% reference range. You can see the deficiency of the definition of MI. Thelin et al. Mokhtari et al. But maybe not. Imagine if you had only recorded the 2nd ECG.

E-9-1-1 52

E-9-1-1 STEMI ACS Coronary 52

EMS 12-Lead

AUGUST 22, 2022

They are not premature, by definition. The coronary angiogram revealed no critical stenosis, or acute plaque ulceration. Takotsubo should be a diagnosis of exclusion after angiography reveals no obstructive coronary disease, and repeat Echo displays left ventricular recovery. Furthermore, pertinent electrolyte values (e.g.

E-9-1-1 130

E-9-1-1 Coronary ALS ICU 130

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. 1, 2] The most clinically useful definition to account for this entire constellation is intraventricular conduction delay. Attached is the first ECG. Isn’t VT ALWAYS “wide”?

ALS 130

ALS STEMI Coronary OR 130

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

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-9-1-1 119

E-9-1-1 Coronary ACS BLS 119

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

Hospital Course The patient was taken emergently to the cath lab which did not reveal any significant coronary artery disease, but she was noted to have reduced EF consistent with Takotsubo cardiomyopathy. Reference on Troponins: Xenogiannis I, Vemmou E, Nikolakopoulos I, et al. It can only be seen by IVUS. MINOCA has many etiologies.

Emergency Department 52

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

Dr. Smith's ECG Blog

AUGUST 9, 2024

Serial ECGs enhance the diagnosis of acute coronary syndrome. Although recognition of OMI was not affected by administration of morphine in this case, use caution with analgesia in ongoing ACS without a definitive plan for angiography. Bigger et al. Sadowski ZP, Alexander JH, Skrabucha B, et al. Leave it alone.

STEMI 85

STEMI Coronary Heart Attack ACS 85

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. Clin Exp Emerg Med 2023. CHEST 2010.

ALS 137

ALS ACS OR CPR 137

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. There is no definite evidence of acute ischemia. (ie,

Defibrillator 113

Defibrillator Coronary ALS STEMI 113

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-9-1-1 117

E-9-1-1 OR Coronary ACS 117

Dr. Smith's ECG Blog

JULY 31, 2020

Yet despite this remarkable flaw in the STEMI-paradigm — a substantial number ( if not a frank majority ) of clinicians continue to apply outdated criteria when interpreting ECGs, by refusing to consider prompt cath for definitive diagnosis and reperfusion therapy just because a millimeter-based definition for acute STEMI is not satisfied.

STEMI 52

STEMI Coronary EMR ALS 52

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

When Pendell and I are coding ECGs for the Queen's training, this is one category: "Definite ischemia, difficult to differentiate between posterior OMI and subendocardial ischemia." The De Winter ECG pattern: morphology and accuracy for diagnosing acute coronary occlusion: systematic review. Hayakawa A, Tsukahara K, Miyagawa S, et al.

ACS 83

ACS Coronary ALS CAD 83

Dr. Smith's ECG Blog

SEPTEMBER 11, 2024

Acute MI per se usually does not depress cardiac function and blood pressure enough to cause syncope ( Mostafa et al — J Com Hosp Intern Med Perspect 13(4):9-12, 2023 - ). The initial ECG in today's case was recognized as definitely abnormal — but the question arose as to whether this ECG indicated old infarction vs a new acute event.

EMS 106

EMS CPR ED Coronary 106

Dr. Smith's ECG Blog

JUNE 5, 2023

Aside on ECG Research: 20% of Definite diagnostic STEMI (Cox et al.) have perfect coronary flow by the time of angiogram. Serial tracings often show “ dynamic ” ST-T wave changes — which in a patient with CP, allow prompt definitive diagnosis that might not have been obvious with just a single tracing.

STEMI 79

STEMI Coronary Ambulance ED 79

EMDocs

JULY 1, 2023

Upon further research in the 1970’s, retrospective data from autopsies of those patients showed coronary aneurysms 5 Pathophysiology: Kawasaki Disease is a vasculitis of medium sized arteries. Tomisaku Kawasaki, who noticed 50+ similar pediatric presentations between the years 1961 and 1967. Lakhani, N. BMC Pediatrics. 2018;18(334).

EMS 65

EMS Coronary ED OR 65

Dr. Smith's ECG Blog

APRIL 25, 2023

But the stuttering pain and sudden onset suggest acute coronary occlusion (Occlusion MI, or OMI). Cath lab activation by the ED and I agree with coronary angiography emergently." Result: no angiographically significant obstructive coronary artery disease. Smith and Meyers to diagnose both obvious (STEMI) and subtle OMI.

Coronary 52

Coronary STEMI ALS OR 52

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. 4-6] In figures 1-4, specifically during the episodes of NSVT, there is a mostly regular cadence with preserved definition of both QRS and T. Chapter 10: Recurrent Ventricular Tachycardia (pg.

E-9-1-1 130

E-9-1-1 ALS Coronary EMS 130

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

FEBRUARY 10, 2023

Verouden, Wellens, and Wilde ) submitted a Letter to the Editor to the New England Journal of Medicine ( N Engl J Med 359:2071-2073, 2008 ) — in which they described a “new ECG pattern” without ST elevation that signifies acute occlusion of the proximal LAD ( L eft A nterior D escending ) coronary artery. See text ).

STEMI 52

STEMI ALS Coronary OR 52

REBEL EM

FEBRUARY 22, 2023

Open angle Closed angle Definitions Increased resistance to aqueous outflow through the trabecular meshwork. et al, Emergency Medicine Clinical Essentials ed 2. Ophthalmology, in Marx J et al (eds): Rosens Emergency Medicine: Concepts and Practice, ed 9. Transient vision loss defined as vision loss <24 hours.

Emergency Department 52

Emergency Department ALS ED Coronary 52

Dr. Smith's ECG Blog

MAY 8, 2023

The ACC likely made this new recommendation for the MSC in ventricular paced rhythm in large part due to the "PERFECT" Study (Meyers is an author, and Smith was the senior author): Dodd et al. Electrocardiographic Diagnosis of Acute Coronary Occlusion Myocardial Infarction in Ventricular Paced Rhythm Using the Modified Sgarbossa Criteria.

STEMI 52

STEMI Coronary ED ACS 52

Dr. Smith's ECG Blog

FEBRUARY 13, 2023

Meyers et al. Accuracy of OMI findings versus STEMI criteria for diagnosis of acute coronary occlusion myocardial infarction. Aslanger et al. DIagnostic accuracy oF electrocardiogram for acute coronary OCClusion resulTing in myocardial infarction (DIFOCCULT study). Lemkes et al. Bergmark et al.

STEMI 52

STEMI Paramedic Coronary 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 90

STEMI Coronary Paramedic OR 90

REBEL EM

MARCH 22, 2023

REBEL Core Cast 98.0 – AVNRT Click here for Direct Download of the Podcast Definition: A regular, narrow-complex rhythm with a ventricular rate that is typically > 160 bpm. PMID: 2022022 Appleboam A et al. PMID: 1595533 Ben Yedder N et al. PMID: 21329868 Carlberg DJ et al. Circulation 1991; 83: 1649-59.

ALS 52

ALS EMS ED OR 52

Dr. Smith's ECG Blog

MARCH 9, 2023

Hyperacute T waves do not yet have a formal research definition, but are likely defined best by an increased ratio of area under the curve compared to their QRS complex. Karwowski et al showed that only 64% of 4581 STEMIs had TIMI 0 flow on angiogram. [25] 25] Stone et al found that 72% have TIMI 0 or 1 flow. [26] Circulation.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

EMS 12-Lead

MAY 8, 2022

They are definitely high in amplitude and, intermittently, appear to disproportionately tower over the respective QRS. Cardiology was consulted, who advised to surveil a metabolic process as this did not strike them as acute coronary syndrome. Closer inspection will show that it is Sinus, after all. The serum K returned 8.7,

STEMI 130

STEMI ED EMS Firefighter 130

Dr. Smith's ECG Blog

MAY 13, 2020

Sensitivity of POCUS even for definite wall motion abnormalities is far from perfect. Smith presented results from a 2019 article by Harhash et al, that confirm how the ECG pattern shown in Figure-1 does not represent acute LMain occlusion — but rather the differential diagnosis that I show above.

Coronary 52

Coronary ACS EMS ALS 52

EMDocs

NOVEMBER 6, 2023

It is reasonable to administer vasodilators (eg, nitrates, phentolamine, calcium channel blockers) for patients with cocaine-induced coronary vasospasm or hypertensive emergencies. Editorial Comment : Use standard BLS/ALS measures, especially if in cardiac arrest. COR 2a, LOE C-LD. COR 2a, LOE C-LD. COR 1, LOE C-LD. COR 2a, LOE B-NR.

Naloxone 94

Naloxone OR Overdose BLS 94

Dr. Smith's ECG Blog

JANUARY 5, 2024

80%) and definitely too much for hour to hour. However, the Definition of MI requires at least one value above the 99th percentile, which for a male is 34 ng/L (16 ng/L for women). Heitner et al. Our patient already has an ECG diagnostic for OMI, so this finding is useless.) HsTnI drawn at that time was 9 ng/L (ref.

ACS 107

ACS ALS OR STEMI 107

Dr. Smith's ECG Blog

DECEMBER 29, 2023

STEMI criteria is bad at differentiating between normal variant and acute coronary occlusion or reperfusion, and initial troponin levels don't differentiate between occlusive and non-occlusive MI 3. the presence of J waves from early repolarization doesn’t rule out an acute coronary occlusion 4. McLaren et al, including Meyers/Smith.

STEMI 70

STEMI Coronary OR ALS 70

Dr. Smith's ECG Blog

OCTOBER 3, 2018

When he showed it to me, I said "Ouch, looks like an acute coronary occlusion. no LBBB or paced rhythm), acute coronary occlusion MI (OMI) is diagnosed in approximately 75% of cases. Khan AR, Golwala H, Tripathi A, et al. Acute myocardial infarction (AMI) was defined by the Third Universal Definition of AMI.

Coronary 52

Coronary STEMI Paramedic ALS 52

Dr. Smith's ECG Blog

APRIL 22, 2022

Backus BE, Six AJ, Kelder JC, et al. Moumneh T, Sun BC, Baecker A, et al. Identifying patients with low risk for acute coronary syndrome without troponin testing: validation of the HEAR score. Shah ASV, Anand A, Sandoval Y, et al. Patel J, Alattar F, Koneru J, et al. Gulati M, Levy P, Mukherjee D, et al.

E-9-1-1 52

E-9-1-1 STEMI ALS ED 52

Dr. Smith's ECG Blog

NOVEMBER 5, 2023

By Magnus Nossen, edits by Grauer and Smith The patient is a 70-something female with DMII, HTN and an extensive prior history of coronary artery disease and myocardial infarctions. To say that these deflections are definite proof of ventricular pacing would not be correct. She's had multiple PCI procedures.

Coronary 101

Coronary OR ALS 101

Dr. Smith's ECG Blog

MAY 31, 2023

Association of intravenous morphine use and outcomes in acute coronary syndromes: Results from the CRUSADE Quality Improvement Initiative. de Winter et al in N Engl J Med 359:2071-2073, 2008. Meine TJ, Roe M, Chen A, Patel M, Washam J, Ohman E, Peacock W, Pollack C, Gibler W, Peterson E. Am Heart J. 2005;149:1043–1049. Singer DD.

STEMI 81

STEMI Coronary ACS OR 81

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

The diagnostic coronary angiogram identified only minimal coronary artery disease, but there was a severely calcified, ‘immobile’ aortic valve. Author continued : STE in aVR is often due to left main coronary artery obstruction (OR 4.72), and is associated with in-hospital cardiovascular mortality (OR 5.58).

Coronary 52

Coronary ACS ALS STEMI 52

Dr. Smith's ECG Blog

OCTOBER 6, 2023

Smith: this is the definition of LV aneurysm) --Regional wall motion abnormality- apical anterolateral and apical inferior, akinetic. de Winter et al in N Engl J Med 359:2071-2073, 2008. --The estimated left ventricular ejection fraction is 20 %. Figure-1: The de Winter T Wave Pattern , as first described by Robbert J.

ALS 66

ALS Coronary OR 66

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). Aspirin 81 mg daily.

STEMI 52

STEMI Coronary ACS ED 52