Dr. Smith's ECG Blog

DECEMBER 5, 2023

Acute coronary syndrome in a pediatric patient? Ultimately, cardiac cath was done — revealing patent coronary arteries. Written by Kirsten Morrissey, MD with edits by Bracey, Grauer, Meyers, and Smith An older teen was transferred from an outside hospital with elevated serum troponin and and ECG demonstrating ST elevations.

Coronary 112

Coronary CAD ACS ALS 112

Dr. Smith's ECG Blog

MAY 13, 2024

Dr. Smith and other authors showed the utility of Speckle Tracking Strain Echo in this case report: Diagnosis of acute coronary occlusion in patients with non–STEMI by point-of-care echocardiography with speckle tracking Repeat ECG: Slightly less hyperacute T waves, likely indicating improving flow compared to the first ECG.

OR 108

OR STEMI Heart Attack Coronary 108

Dr. Smith's ECG Blog

JUNE 5, 2024

Why Was Cardiac Cath Negative for Coronary Disease? As noted by Dr. Nossen — this patient qualified as MINOCA ( M yocardial I nfarction with N on- O bstructive C oronary A rteries ) — since troponin was positive on his 2nd admission, yet there was no evidence of obstructive coronary disease on cath.

Coronary 107

Coronary ACS ALS OR 107

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

Here is the post shock ECG: Cardiology was called stat for ischemic VT, query SCAD vs thrombotic occlusion vs coronary vasospasm. Cath lab was activated: There was no coronary artery disease, but there was spontaneous coronary artery dissection (SCAD) of the distal LAD, which was narrowed by 95%, and treated medically.

OR 66

OR STEMI ACS Coronary 66

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 110

Defibrillator Coronary Epinephrine ACS 110

Dr. Smith's ECG Blog

NOVEMBER 14, 2024

Apparently the intern also recognized it (he is an avid reader of the blog), but the staff overruled him." = My Comment , by K EN G RAUER, MD ( 11/14 /2024 ): = I share Dr. Smith's disappointment with regard to the failure to recognize the obvious acute OMI evident on today's initial ECG ( that I've reproduced and labeled in Figure-1 ).

ED 116

ED Coronary Paramedic OR 116

Dr. Smith's ECG Blog

NOVEMBER 11, 2024

It can be seen in other forms of heart block as well (such as complete heart block). See Ken Grauer 's comment below for more on this. As this patient is scheduled for imminent elective surgery, it is important to determine whether this is Mobitz I (benign) or Mobitz II (requires pacing). So.Which is it? History is often helpful.

OR 71

OR E-9-1-1 Coronary 71

Dr. Smith's ECG Blog

MAY 10, 2023

A CT Coronary angiogram was ordered. Here are the results: --Minimally obstructive coronary artery disease. --LAD Although a lesion is not visible anatomically on this CT scan, coronary catheter angiography could be considered based on Cardiology evaluation." A repeat troponin returned at 0.45 CAD-RADS category 1. --No

Coronary 52

Coronary STEMI CAD OR 52

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

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 105

Coronary EMS OR 105

Dr. Smith's ECG Blog

SEPTEMBER 9, 2024

You can easily imagine this patient getting one of several diagnoses -- vasospasm, MINOCA , pericarditis, or maybe even no diagnosis at all beyond "non-obstructive coronary artery disease." Another option would be to use Optical Coherence Tomography for Coronary Imaging ). That plaque is at risk of thrombosing again.

OR 66

OR Coronary ACS EMS 66

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 125

Coronary ACS Emergency Department Defibrillator 125

Dr. Smith's ECG Blog

OCTOBER 8, 2024

In the context of this woman in her 60s who has known coronary disease ( and who is now presenting with acute chest discomfort ) — I interpreted neighboring leads V1 and V2 as part of the same acute process suggested by the QRST in lead V3. For more on Precordial Swirl — See the October 15, 2022 post in Dr. Smith's ECG Blog ).

OR 108

OR STEMI ICU Coronary 108

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 91

Coronary CAD ACS OR 91

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. At 1321, a repeat troponin I returned at 0.62

Coronary 108

Coronary STEMI Emergency Department OR 108

Dr. Smith's ECG Blog

OCTOBER 1, 2023

This patient in today's case was a man in his 60s with a known history of coronary disease, including prior stents. But in a patient with known coronary disease — who presents with new symptoms and the above ECG changes — any amount of Troponin elevation has to be taken as indicative of an acute event until proven otherwise.

OR 126

OR STEMI Coronary CAD 126

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. Does the ECG normalize?

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 ). What do you do clinically when the ECG looks like this?

E-9-1-1 110

E-9-1-1 Coronary STEMI ALS 110

Dr. Smith's ECG Blog

NOVEMBER 29, 2023

This new ECG was still interpreted as STEMI and the patient was taken to the cath lab where the angiogram showed completely normal coronary arteries throughout. Smith : this ECG is definitely not OMI, but could be mistaken for Swirl pattern, which is a septal OMI with STE in V1 and STD in V6. Unfortunately no echo was available.

OR 116

OR STEMI EMS ED 116

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. But does this matter?

STEMI 118

STEMI Coronary ALS CAD 118

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 ). This was sent to me from Sam Ghali ( @EM_Resus ) with no other information. What do you think, Steve?

E-9-1-1 111

E-9-1-1 Coronary ALS ED 111

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

Dr. Smith's ECG Blog

SEPTEMBER 22, 2023

This is diagnostic of full reperfusion.] An old ECG was found: As you can see, this patient has zero baseline STE, and normal T-waves. You never know if a patient's baseline has normal large STE or complete absence of STE, or somewhere in between. 90% of normals have some STE in V2 and V3. I focus my comment on this initial ECG in today's case.

OR 123

OR STEMI Coronary 123

Dr. Smith's ECG Blog

AUGUST 6, 2023

Doing so allows you to put YOURSELF to the TEST ( keeping in mind that all ECGs shown are from patients with chest pain suggestive of potential acute coronary disease ). Smith shows a new ECG. So — FREEZE the picture of each ECG on the screen — FORCE yourself to commit to an answer.

OR 96

OR STEMI Coronary 96

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

NOVEMBER 1, 2022

The 50-something patient with history of coronary stenting and slightly reduced LV ejection fraction. which would suggest reduced rates of major adverse cardiac events with coronary artery bypass grafting." On the other hand, stable EKG over an hour in the setting of ongoing acute coronary syndrome is again unusual.

Overdose 52

Overdose OR Coronary ACS 52

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. Pattern A evolves into Pattern B. Am Heart J. 2000;139:430–436. Am J Cardiol.

Coronary 117

Coronary STEMI ED OR 117

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

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? Why did I say that?

Coronary 136

Coronary OR EMS ED 136

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 108

Coronary CAD CPR Critical Care 108

Dr. Smith's ECG Blog

JULY 7, 2024

First trop was 7,000ng/L (normal 25% of ‘Non-STEMI’ patients with delayed angiography have the exact same pathology of acute coronary occlusion. The new ACC expert consensus explains that: “STEMI ECG criteria on a standard 12-lead ECG alone will miss a significant minority of patients who have acute coronary occlusion. Take home 1.

STEMI 66

STEMI Coronary ALS OR 66

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

REBEL EM

SEPTEMBER 14, 2023

Control: 53.4% D ECLS: 18.2% Control 8.7% Control 38.0% Majority of patients had PCI performed (96.6%) Impella CP was most common mechanical circulatory support in patients without ECLS (85.7%) Death From Any Cause at 30d ECLS: 47.8% Control: 49.0% RR 0.98; 95% CI 0.80 to 1.19; p = 0.81 vs 13.9% (RR 0.58; 95% CI 0.33 vs 22.6% (RR 1.03; 95% CI 0.88

Life Support 137

Life Support Coronary CPR ICU 137

Dr. Smith's ECG Blog

DECEMBER 11, 2023

For the same reason, you should not delay coronary angiography because pain resolves with morphine. When I see this, I always look at V2 for any evidence of posterior OMI (STD, or loss or inversion of T-wave, or downsloping ST segment: there is a negative T-wave ), and V6 for any STE (normal). So I would be worried about inferior OMI.

E-9-1-1 121

E-9-1-1 ACS Coronary STEMI 121

Dr. Smith's ECG Blog

MARCH 17, 2024

Although radiation into the left arm is most classic for coronary ischemia, radiation into both arms is actually modestly more predictive ). ECG 1 Readers of this blog will have no trouble recognizing this as an OMI with some early reperfusion. Answer: This is MINOCA -- Myocardial Infarction with Non-Obstructive Coronary Arteries.

Coronary 71

Coronary OR 71

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 123

CAD STEMI Coronary ACS 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 109

STEMI Coronary Emergency Department OR 109