REBEL EM

SEPTEMBER 12, 2022

Background: Coronary artery disease can result in hibernating myocardium (chronic myocardial contractile dysfunction) due to ischemia. The theory is that there is reduced coronary blood flow and increased myocardial demand resulting in impaired contractility. Paper: Perera D et al. OMT: 38.0% HR 0.99; 95% CI 0.78 to 1.27; p = 0.96

Coronary 52

Coronary ALS OR EMS 52

EMDocs

FEBRUARY 7, 2024

GLP-1 agonists are also associated with improved ejection fraction, coronary blood flow, and cardiac output while reducing the risk of cardiovascular events, infarction size, and all-cause mortality. Adverse events are common in those using GLP-1 agonists, but the vast majority of these are minor. What are the complications?

Allergic Reaction 75

Allergic Reaction ALS CAD OR 75

The Skeptics' Guide to EM

MAY 19, 2018

[display_podcast] Date: May 16, 2018 Reference: Freund et al. Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events
 Among Low-Risk Emergency Department Patients: The PROPER Randomized Clinical Trial. display_podcast] Date: May 16, 2018 Reference: Freund et al. Reference: Freund et al.

Emergency Department 130

Emergency Department ALS Coronary OR 130

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 121

Coronary STEMI ED OR 121

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

JANUARY 9, 2023

Repeat CT angio chest (not CT coronary, unclear what protocol) showed possible LAD aneurysm and thrombus. Finally, coronary angiography was performed (at least 5 days after presentation) which confirmed LAD aneurysm with large thrombus burden, TIMI 0 flow, thrombectomy performed. Smith’s ECG Blog of young adults with acute MI ).

Coronary 52

Coronary STEMI Heart Attack OR 52

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

Studies such as those by Moise et al 14 and Ellis et al 39 have shown that the relative risk of developing an acute myocardial infarction in the territory supplied by an artery with a 70%. Furthermore, if this occurs at all, it is a rare event. years, with the interval as long as 12 or 18 years in some studies.

Coronary 80

Coronary ACS OR EMR 80

The Skeptics' Guide to EM

JUNE 14, 2017

Thank you to Dr. Manrique Umana for inviting me and the conference organizers for putting on such an amazing and educational event. Thank you to Dr. Manrique Umana for inviting me and the conference organizers for putting on such an amazing and educational event. A number of examples of the KT problem were provided.

Coronary 130

Coronary Emergency Department ALS 130

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 106

STEMI Coronary OR ALS 106

Dr. Smith's ECG Blog

JULY 27, 2023

I was not worried for a coronary etiology. Under most circumstances — this combination of ECG findings would point to an acute event. PEARL #3: The pathophysiologic mechanism for producing amphetamine-induced acute MI is unclear ( Bazmi et al — SQUMJ 17(10); e31-37, 2017 — and — Sinha et al — Case Rep Cardiol, 2016 ).

Coronary 52

Coronary ACS Naloxone Plasma 52

Dr. Smith's ECG Blog

SEPTEMBER 7, 2024

Lemkes et al. 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. Eur Heart J 2018. Full text link. Am Heart J.

STEMI 116

STEMI ACS Critical Care OR 116

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 105

STEMI Coronary ACS ED 105

Dr. Smith's ECG Blog

SEPTEMBER 16, 2024

A coronary angiogram was done that did not show significant coronary artery disease. Events in Panel B — suggest a different clinical situation. Most Torsades is the result of a pause-dependent effect that predisposes to development of the malignant arrhythmia ( Dohadwala et al — Heart Rhythm Case Rep 3(2):115-119, 2017 ).

Defibrillator 70

Defibrillator Coronary OR ALS 70

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

The De Winter ECG pattern: morphology and accuracy for diagnosing acute coronary occlusion: systematic review. Hayakawa A, Tsukahara K, Miyagawa S, et al. Immediate and early percutaneous coronary intervention in very high-risk and high-risk non-ST segment elevation myocardial infarction patients. 2009;95:1701–1706. As per Drs.

ACS 87

ACS Coronary ALS CAD 87

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. ST depression that is maximal in leads V2-to-V4.

STEMI 52

STEMI Coronary EMR ALS 52

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 28, 2022

Learn about the Smith-Modified Sgarbossa Criteria for Diagnosis of OMI Paced Rhythm: Dodd, Meyers, Smith, et al. Electrocardiographic diagnosis of acute coronary Occlusion Myocardial Infarction in ventricular paced rhythm using the modified Sgarbossa criteria. Annals of Emergency Medicine 2021. Figure-1: The 2nd ECG in today's case. (

Coronary 52

Coronary Paramedic EMS ICU 52

Dr. Smith's ECG Blog

JANUARY 5, 2024

Heitner et al. 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 PDA plaque was also bulky, but was not described as inflamed or ulcerated. DOI:10.1161/CIRCINTERVENTIONS.118.007305), DOI:10.1161/CIRCINTERVENTIONS.118.007305),

ACS 110

ACS ALS OR STEMI 110

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. PLUS — Today's patient is an older woman with known severe coronary disease who presented with new chest pain. She's had multiple PCI procedures.

Coronary 104

Coronary OR ALS 104

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

MARCH 9, 2023

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] 26] Finally, Cox et al found that 80% had TIMI 0, 1, or 2.27 Karwowski et al showed that only 64% of 4581 STEMIs had TIMI 0 flow on angiogram. [25] Pol Arch Intern Med.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

REBEL EM

SEPTEMBER 5, 2022

Paper 1: Schmidt HJ et al. PMID: 360027567 [ Access on Read by QxMD ] Paper 2: Kjaergaard J et al. References: Schmidt HJ et al. PMID: 360027567 [ Access on Read by QxMD ] Kjaergaard J et al. A higher MAP may offer advantages due to improved cerebral perfusion pressure, however data is lacking. Liberal O2: 33.9%

ICU 52

ICU ALS OR CPR 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. 3–8 Shi et al. In acute MI, the T-wave is large, and the T/ST ratio is high. This is much more typical of myocarditis. Angiogram was negative.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

AAEM RSA

AUGUST 27, 2020

1 The primary goal of cardiopulmonary resuscitation (CPR) is to optimize coronary perfusion pressure and maintain systemic perfusion in order to prevent neurologic and other end-organ damage while working to achieve ROSC. Nielsen N, Wetterslev J, Cronberg T et al. By the time of the study by Nielsen et al. Kirkegaard et al.

E-9-1-1 52

E-9-1-1 CPR ICU ALS 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). Aspirin 81 mg daily.

STEMI 52

STEMI Coronary ACS 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. Thelin et al. Mokhtari et al.

E-9-1-1 52

E-9-1-1 STEMI ACS Coronary 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. Stein et al. This is a paper worth reading : Marchik et al.

ACS 52

ACS Coronary ALS ICU 52

Dr. Smith's ECG Blog

AUGUST 19, 2023

Herzog et al. Khan et al. We need to remember that not all patients with acute ( or recent ) MI have chest pain with their event. 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

APRIL 17, 2023

CASE #2: I am more disturbed by learning of the events associated with the ECG in Case #2. NOTE: For illustrative purposes — I’ve adapted Figure-1 from the original manuscript by deWinter et al, published in this 2008 NEJM citation. de Winter et al in N Engl J Med 359:2071-2073, 2008. See text ).

OR 52

OR STEMI ACS Emergency Department 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

JANUARY 15, 2023

Acute 100% coronary occlusion can be VERY subtle on the ECG. Hillinger et al. IF ever in doubt about whether an acute event may be ongoing — Repeat the ECG within 10-to-15 minutes ( since dynamic ST-T wave changes during an actively evolving event may occur with surprising rapidity ). Learning Points: 1.

Coronary 52

Coronary ALS OR 52

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

Takotsubo is a sudden event, not one with crescendo angina. 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. An angiogram is a "lumenogram;" most plaque is EXTRALUMINAL!!

Emergency Department 52

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

Dr. Smith's ECG Blog

SEPTEMBER 7, 2020

mg/kg IV is administered if no response is seen and no significant drug-induced adverse event occurs. SVT misdiagnosed as panic disorder Lessmeier TJ, Gamperling D, Johnson-Liddon V, et al. Lessmeier et al. I’ll add here 2 more reference links on the subject — by Brugada; Diez — and — by Tondo et al. mg/kg IV over 2 min.

E-9-1-1 52

E-9-1-1 ALS OR Coronary 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

The Skeptics' Guide to EM

APRIL 15, 2023

Date: April 12, 2023 Reference: Weizmann et al. Date: April 12, 2023 Reference: Weizmann et al. Background: Sudden cardiac arrest (SCA) is a rare but serious event that can occur in athletes during training or competition. Reference: Weizmann et al.

ALS 136

ALS Coronary OR 136

Dr. Smith's ECG Blog

JULY 22, 2023

The patient proceeded to cath where all coronaries were described as normal with no evidence of any CAD, spasm, or any other abnormality. In the largest study looking at this topic by Mizusawa et al., Recently the rate of true arrhythmic events related to fevers in the classic Brugada Type 1 syndrome was explored by Michowitz et al.

E-9-1-1 70

E-9-1-1 CAD OR STEMI 70

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. Whether this represents a potential acute cardiac event would depend on the history, comparison with prior tracings and serial tracings. 4] Baranchuk, A, et al.

ALS 130

ALS STEMI Coronary OR 130