EMS 12-Lead

AUGUST 22, 2022

Beats 9-12 : Continuation of the previously described events, all inducible by the pause (and thus, prolongation of refractoriness) created by the PVC of Beat 8. The coronary angiogram revealed no critical stenosis, or acute plaque ulceration. Beat 4 abruptly halts this repetitious cycle via Peel Back. References Chiale, P. Saini, A.,

E-9-1-1 130

E-9-1-1 Coronary ALS ICU 130

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-9-1-1 126

E-9-1-1 Coronary ACS BLS 126

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-9-1-1 122

E-9-1-1 Coronary ALS ED 122

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

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 98

Allergic Reaction ALS CAD OR 98

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 116

STEMI Coronary ACS ED 116

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

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 113

EMS CPR ED Coronary 113

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

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 119

ACS ALS OR STEMI 119

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

NOVEMBER 15, 2013

It shows that on a 7 day angiogram, only 58% of re-occlusions were symptomatic: Ohman EM, Califf RM, Topol EJ et al. It is important to recognize that coronary thrombosis is dynamic , with spontaneous opening and lysing of the thrombus in the infarct-related artery (we all have endogenous tPA and plasmin to lyse thrombi).

Coronary 52

Coronary STEMI ALS Emergency Department 52

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

EMDocs

OCTOBER 30, 2023

16 In a study conducted by Millet et al. A retrospective study done in May 2023, by Shaish et al 24 showed a 30 % reduction in accuracy of NCCT compared to CECT in a study done among 201 adult ED patients with abdominal pain. link] Bellolio MF, Heien HC, Sangaralingham LR, et al. References Abelson R. The New York Times.

E-9-1-1 101

E-9-1-1 Emergency Department ALS CCT 101

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. The fatter-than-it-should-be T wave in lead aVL is the mirror image opposite picture of the ST-T wave in lead III ==> reciprocal change that strongly suggests a recent ( if not still ongoing acute ) event.

STEMI 96

STEMI Coronary ED Ambulance 96

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 115

STEMI ACS Critical Care Coronary 115

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

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 111

Coronary OR ALS 111

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 81

ACS Coronary ALS CAD 81

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

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

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 69

STEMI Coronary OR ALS 69

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 ICU EMS 52

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 40

Coronary ACS ALS STEMI 40

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

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 98

STEMI ACS OR ALS 98

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

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 67

Defibrillator Coronary OR ALS 67

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 40

ACS Coronary ALS ICU 40

ACEP Now

AUGUST 12, 2024

Sequence of events in angina at rest: Primary reduction in coronary flow. Normalization of abnormal T waves in ischemia. Arch Intern Med. 1976 Apr;136(4):391-5. Chierchia S, Brunelli C, Simonetti I, Lazzari M, Maseri A. Circulation. 1980 Apr;61(4):759-68. Simons A, Robins LJ, Hooghoudt TE, Meursing BT, Oude Ophuis AJ.

Emergency Department 52

Emergency Department STEMI ACS ED 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

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

DECEMBER 29, 2015

The criteria of Armstrong et al. LVH can mimic an acute anterior coronary occlusion (ACO) on the ECG. One retrospective analysis by Armstrong et al. Electrocardiographic left ventricular hypertrophy in chest pain patients: Differentiation from acute coronary ischemic events. AT, Jaffa EJ, et al. J Emerg Med.

STEMI 40

STEMI Coronary ALS CAD 40

Dr. Smith's ECG Blog

MAY 19, 2022

Ct coronary angiogram showed normal coronary arteries. Smith note: I think CT coronary angiogram is reasonable with the elevated troponins and symptoms. The Cardiorespiratory Implications of Ultra-marathon Bjørkavoll‐Bergseth et al. Paana et al. He was diagnosed with mild AKI which resolved. ng/L; 3 hours, 38.3

E-9-1-1 52

E-9-1-1 Coronary OR ED 52

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

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

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