Dr. Smith's ECG Blog

JUNE 5, 2024

IMPRESSION: The finding of sinus bradycardia with 1st-degree AV block + marked sinus arrhythmia + the change in PR interval from beat #5-to-beat #6 — suggests a form of vagotonic block ( See My Comment in the October 9, 2020 post in Dr. Smith's ECG Blog ). Why Was Cardiac Cath Negative for Coronary Disease?

Coronary 122

Coronary ACS ALS OR 122

EMS 12-Lead

AUGUST 18, 2024

Readers of the Smith ECG Blog will probably recognize this a very subtle inferior OMI. Ultimately the patient went to Cath and was found to have multi-vessel obstructive coronary disease with an acute LCX culprit vessel, which was stented. The VT vs SVT with Aberrancy debate is beyond the scope of this particular blog post.

CAD 147

CAD EMT EMT ACS 147

EMOttawa

APRIL 9, 2024

Question and Methods: The authors completed preplanned subgroup analyses to determine if a 0-1 hour ultra-sensitive troponin […] The post Sensitivity Cardiac Troponin T Among Patients With Known Coronary Artery Disease appeared first on EMOttawa Blog.

Coronary 63

Coronary ALS 63

Emergency Medicine Cases

NOVEMBER 19, 2019

In this ECG Cases blog we look at 8 patients with potentially ischemic symptoms, to highlight pearls and pitfalls of inferior MI. Can you identify which ones had acute coronary occlusion? The post ECG Cases 3: Can you find the subtle inferior MI? appeared first on Emergency Medicine Cases.

Coronary 130

Coronary STEMI EMS 130

The Skeptics' Guide to EM

OCTOBER 20, 2018

She is author of the blog, The Short Coat , and cofounder of the emergency medicine podcast, FOAMcast. The acute coronary syndrome work-up is negative but she is Well’s high and needs a CTPA to rule-out a pulmonary embolism. Case: A 64-year-old woman with type-2 diabetes. Acute Kidney Injury After Computed Tomography: A Meta-analysis.

Coronary 183

Coronary Emergency Department ALS OR 183

Emergency Medicine Cases

DECEMBER 16, 2019

In this ECG Cases blog we look at seven patients with potentially ischemic symptoms and subtle ECG changes in the lateral leads. Which had acute coronary occlusion? Introducing the concept of Occlusion MI - a paradigm shift in ECG diagnosis of MI. The post ECG Cases 4: Lateral STEMI or Occlusion MI?

STEMI 130

STEMI OR Coronary 130

Emergency Medicine Cases

MARCH 10, 2020

Which had acute coronary occlusion? Jesse McLaren guides us through the differential diagnosis of ST elevation in aVR with diffuse ST depression in this ECG Cases blog. 10 patients presented with the "STEMI-equivalent" ST elevation in aVR with diffuse ST depression. The post ECG cases 7: ST elevation in aVR, STEMI-equivalent?

STEMI 130

STEMI Coronary EMS 130

Emergency Medicine Cases

SEPTEMBER 15, 2020

In this ECG Cases blog we look at 6 patients who presented with potentially ischemic symptoms and LVH on their ECG. Which had an acute coronary occlusion? The post ECG Cases 13: LVH and Occlusion MI appeared first on Emergency Medicine Cases.

STEMI 130

STEMI Coronary OR EMS 130

REBEL EM

SEPTEMBER 21, 2023

What Your Gut Says: The patient has a tachydysrhythmia which may be the presentation of acute coronary syndrome (ACS) even though the patient has no ischemic symptoms. Essentially, we are using the troponin assay to find patients with ACO who may be benefited by coronary interventions or risk factor modification.

Coronary 143

Coronary ACS ED OR 143

Dr. Smith's ECG Blog

JULY 25, 2024

But cardiac arrest is a period of near zero flow in the coronary arteries and causes SEVERE ischemia. As we have often emphasized on Dr. Smith's ECG Blog ( See My Comment in the March 1, 2023 post) — DSI does not indicate acute coronary occlusion! It also does not uniformly indicate severe coronary disease.

Defibrillator 124

Defibrillator Coronary Epinephrine ACS 124

Dr. Smith's ECG Blog

APRIL 9, 2024

Before the lab values returned this patient had a n emergent coronary CT angiogram done that ruled out CAD. A false positive cath lab activation is also off course acceptable for this diagnosis if you cannot get an emergent coronary CT angiogram. Each main coronary artery (LAD, RCA and LCx) are shown in separate images.

Coronary 108

Coronary CAD ACS OR 108

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

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-9-1-1 128

E-9-1-1 Coronary STEMI ALS 128

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. A Bayesian approach to acute coronary occlusion.

STEMI 121

STEMI Coronary ALS CAD 121

REBEL EM

JUNE 1, 2023

Indication for emergency invasive coronary angiography or had coronary angiography within 1 hour of arrival. Known obstructive coronary artery disease or known coronary stent. appeared first on REBEL EM - Emergency Medicine Blog. Excluded: Obvious cause for OHCA prior to SDCT or on hospital arrival.

Coronary 145

Coronary Defibrillator CPR ALS 145

Dr. Smith's ECG Blog

SEPTEMBER 19, 2023

Past medical history includes coronary stenting 17 years prior. Cardiology was consulted and the patient underwent coronary angiogram which showed diffuse severe three-vessel disease. Coronary angiogram shows diffuse severe three-vessel disease. Initial ED ECG: What do you think? IV Diltiazem was Contraindicated!

Coronary 139

Coronary OR EMS ED 139

Dr. Smith's ECG Blog

JUNE 23, 2024

The patient was treated as possible NSTEMI and underwent coronary angiography about 4 hours after presentation. TIMI 3 means the rate of passage of dye through the coronary artery is normal by angiography.) The electrophysiologist is a reader of Dr. Smith's ECG Blog. Initial hsTnI was 384 ng/L. He did not have access to ECG 1.

Coronary 118

Coronary CAD CPR Critical Care 118

Dr. Smith's ECG Blog

MAY 5, 2024

An undergraduate (not yet in medical school) who works as an ED technician (records all EKGs, helps with procedures, takes vital signs) and who reads this blog regularly arrived at work and happened to glance down and see this previously recorded ECG on a table in the ED. It was recorded at 0530: What do you think?

ED 124

ED STEMI Coronary Paramedic 124

REBEL EM

OCTOBER 25, 2023

Take Home Points: A CCTA is an anatomic test to determine if a patient has normal coronary arteries, non-obstructive disease, or obstructive disease. Take Home Points: A CCTA is an anatomic test to determine if a patient has normal coronary arteries, non-obstructive disease, or obstructive disease.

Coronary 103

Coronary EMS OR 103

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

A 56 year old male with a history of diabetes, dyslipidemia, hypertension, and coronary artery disease presented to the emergency department with sudden onset weakness, fatigue, lethargy, and confusion. Regular readers of this ECG Blog will be well familiar with many of these points. No ECG was ordered on Day #1.

Coronary 120

Coronary STEMI Emergency Department OR 120

EMOttawa

DECEMBER 18, 2023

The post Modification of the GRACE Risk Score for Risk Prediction in Patients With Acute Coronary Syndromes appeared first on EMOttawa Blog. JAMA Cardiol. 2023 Oct 1;8(10):946-956 Question: Does the modified GRACE score incorporating continuous troponin improve ACS risk prediction? Methods: Retrospective.

Coronary 52

Coronary ACS ALS 52

Dr. Smith's ECG Blog

SEPTEMBER 15, 2023

More cases can be found on the blog here. Here it is: So we looked for the followup: Cath lab was activated per protocol and coronary angiogram found no angiographic significant obstructive disease in the LAD, LCX, and RCA. "Look how bizarre it is." When bizarre, look at leads I, II, and III. So I explained APTA to him.

STEMI 135

STEMI Coronary 135

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]. It relies on an 1 mm cut point, which this blog does not favor as an approach to ECG. Back to the case. Iwaoka, R.

E-9-1-1 131

E-9-1-1 OR Coronary ACS 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

APRIL 22, 2024

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

Coronary 118

Coronary STEMI ED OR 118

Dr. Smith's ECG Blog

OCTOBER 20, 2024

The ST segment changes are compatible with severe subendocardial ischemia which can be caused by type I MI from ACS or potentially from type II MI (non-obstructive coronary artery disease with supply/demand mismatch). This patient is actively dying from a left main coronary artery OMI and cardiac arrest from VT/VF or PEA is imminent!

Coronary 128

Coronary ACS Emergency Department Defibrillator 128

Dr. Smith's ECG Blog

OCTOBER 3, 2024

Coronaries were clean. While statistical likelihood of acute OMI is clearly lower in younger adults — nothing is ruled out by age alone ( as per My Comment in the January 9, 2023 and December 5, 2023 posts in Dr. Smith's ECG Blog ). Sam : "Yes, this case was sent to me. It was a man in his 30s with chest pain. 27 post ).

E-9-1-1 124

E-9-1-1 Coronary ALS ED 124

REBEL EM

SEPTEMBER 14, 2023

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. Control: 53.4% D ECLS: 18.2% Control 8.7% Control 38.0% Control: 49.0% RR 0.98; 95% CI 0.80 to 1.19; p = 0.81 Control: 9.6%

Life Support 136

Life Support Coronary CPR ICU 136

Dr. Smith's ECG Blog

DECEMBER 7, 2023

I quickly reviewed the patient’s records and saw that she was a 53 year old woman with a history of BMI 40, but no other identifiable risk factors for coronary artery disease. In this patient with stuttering symptoms and rising troponin, there is no other option but to perform emergent coronary angiography. Hers is shown below.

Coronary 124

Coronary OR 124

Dr. Smith's ECG Blog

MARCH 10, 2025

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! See > 50 cases on Dr. Smiths EGC Blog. Smith comment: this is even more stupid.

STEMI 89

STEMI OR Coronary Emergency Department 89

The Skeptics' Guide to EM

APRIL 10, 2021

He has a wonderful #FOAMed blog and podcast called Broomedocs and also work […] The post SGEM#326: The SALSA Study: Hypertonic Saline to Treat Hyponatremia first appeared on The Skeptics Guide to Emergency Medicine. He has a wonderful #FOAMed blog and podcast called Broomedocs and also work with me on the Primary Care RAP team.

Emergency Department 130

Emergency Department Coronary ED OR 130

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

MAY 20, 2024

This was sent by an undergraduate (not yet in medical school, but applying now) who works as an ED technician (records all EKGs, helps with procedures, takes vital signs) and who reads this blog regularly. They too have dense white masses consistent with coronary atherosclerosis. Edited by Smith He also sent me this great case.

CAD 126

CAD STEMI Coronary ACS 126

Dr. Smith's ECG Blog

DECEMBER 11, 2023

For the same reason, you should not delay coronary angiography because pain resolves with morphine. A few hours later, the patient underwent coronary angiography, which showed complete occlusion of her mid left circumflex artery. But pain is a critical signal for urgency in the context of acute coronary syndrome. Mukherjee, D.,

E-9-1-1 123

E-9-1-1 ACS Coronary STEMI 123

EMDocs

DECEMBER 11, 2023

Emergency physicians have recognized for some time that there are many occlusions of the coronary arteries that do not present with classic STEMI criteria on the ECG. This included the addition several new STEMI equivalents [4] on ECG that warrant “prompt evaluation for emergency coronary angiography.”

STEMI 119

STEMI Coronary Emergency Department OR 119

Dr. Smith's ECG Blog

JANUARY 25, 2024

A 40-something with severe diabetes on dialysis and with known coronary disease presented with acute crushing chest pain. As per Dr. Smith — today's patient is a 40-something year old patient with severe diabetes, renal failure and known coronary disease — who presents with “acute crushing CP”. Here is his ED ECG: What do you think?

Coronary 75

Coronary ED OR 75

Dr. Smith's ECG Blog

SEPTEMBER 29, 2024

See Discussion in the June 29, 2024 post of Dr. Smith' ECG Blog ). Although predicting the "culprit" artery of acute coronary occlusion is often straightforward ( ie, based on the distribution of leads with ST elevation and leads with reciprocal ST depression ) — this is not always the case.

STEMI 110

STEMI Coronary Defibrillator OR 110