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

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

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 117

Defibrillator Coronary ALS STEMI 117

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 108

EMS CPR ED Coronary 108

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flaw in the STEMI-paradigm — a substantial number ( if not a frank majority ) of clinicians continue to apply outdated criteria when interpreting ECGs, by refusing to consider prompt cath for definitive diagnosis and reperfusion therapy just because a millimeter-based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 87

ACS Coronary ALS CAD 87

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 66

EMS Coronary ED OR 66

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

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 ).

ALS 52

ALS STEMI 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

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

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 89

STEMI Coronary Paramedic OR 89

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

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

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 110

ACS ALS OR STEMI 110

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 74

STEMI Coronary OR ALS 74

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

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 104

Coronary OR ALS 104

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 80

STEMI Coronary ACS OR 80

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 70

ALS Coronary OR 70

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

Dr. Smith's ECG Blog

AUGUST 19, 2023

Herzog et al. Khan et al. Nothing else is needed — since these 4 leads definitively say, "Acute OMI until proven otherwise". ECG interpretation needs to be done in isolation and then applied to the patient, and this way AI can help identify patients at risk of missed occlusions References 1. Circulation 2007 2.

STEMI 86

STEMI ACS OR ALS 86

Dr. Smith's ECG Blog

JUNE 1, 2022

Moreover, the research which appears to confirm this idea was indeed in relation to the circumflex, but they did not study Occlusion ; rather, they studied asymptomatic coronary disease. I showed conclusively that this is a common finding in normal ECGs, though it is more common in LAD Occlusion than in norml variant STE.

STEMI 52

STEMI Coronary OR ALS 52

Dr. Smith's ECG Blog

APRIL 17, 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 ).

OR 52

OR STEMI ACS Emergency Department 52

Dr. Smith's ECG Blog

DECEMBER 6, 2022

deWinter waves can happen in any coronary artery: see this case and this case = Comment by K EN G RAUER, MD ( 12/6 /2022 ): = Important case for discussion by Dr. McLaren — in that today's patient had a definite MI but no chest pain. Arteries can be totally occluded with flow intermittently maintained by collaterals 6.

STEMI 52

STEMI ACS Coronary OR 52

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-9-1-1 120

E-9-1-1 OR Coronary ACS 120

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

ACEP Now

JULY 7, 2023

Extracorporeal membrane oxygenation Of patients with out-of-hospital cardiac arrest presenting to the ED in refractory VF, a majority have significant coronary artery disease, much of which is amenable to percutaneous coronary intervention. References Tsao CW, et al. Benjamin EJ, et al. Kimblad H, et al.

Defibrillator 98

Defibrillator OR ALS Epinephrine 98

Dr. Smith's ECG Blog

JANUARY 15, 2023

Acute 100% coronary occlusion can be VERY subtle on the ECG. Hillinger et al. Confirmation that the above subtle limb lead changes are real — is forthcoming from the definitely abnormal ST-T waves in leads V2- thru -V6. Regional wall motion abnormality basal inferoseptum, akinetic. Learning Points: 1.

Coronary 52

Coronary ALS OR 52

Dr. Smith's ECG Blog

SEPTEMBER 21, 2022

This is most consistent with ischemia/infarction in the distribution of the left circumflex coronary artery. Meyers, Bracey, Smith, et al. As occurred in today’s case — there are times when despite definitive recognition of posterior OMI by other means — no ST elevation at all will be seen in posterior leads. Learning Points.

STEMI 52

STEMI ED Coronary OR 52

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

NOVEMBER 3, 2017

Here is a video lecture of subtle LAD occlusion: One hour lecture on Subtle ECG Findings of Coronary Occlusion The 3-variable formula comes from this paper: Smith SW et al. The 4-variable formula is based on this paper: Driver, BE et al. He went for Coronary bypass (CABG). 4-variable version still to come. QRS V2 = 15.5

STEMI 52

STEMI Coronary OR ALS 52

Dr. Smith's ECG Blog

OCTOBER 7, 2019

See this paper by Smith et al. Smith pointed out that while atropine may may result in slightly more oxygen demand, the increase in cardiac output and in blood pressure would increase overall coronary perfusion and decrease ischemia. V4R in Right Ventricular MI As in the Smith study of lead V1 in RVMI, Kosuge et al.

STEMI 52

STEMI EMS Coronary ALS 52

Dr. Smith's ECG Blog

JULY 19, 2024

Thus, this meets one of the alternative versions of the modified Sgarbossa criteria that we studied, but not the primary definition on which the publication focused. Lupu et al. Immediate and early percutaneous coronary intervention in very high risk and high risk non-ST segment elevation myocardial infarction patients.

Coronary 106

Coronary STEMI OR ALS 106