ECG Cases 45 ECG in Weakness and Neurological Symptoms
Emergency Medicine Cases
SEPTEMBER 12, 2023
The post ECG Cases 45 ECG in Weakness and Neurological Symptoms appeared first on Emergency Medicine Cases.
Blog Coronary OR 
Dynamic OMI ECG. Negative trops and negative angiogram does not rule out coronary ischemia or ACS.
Dr. Smith's ECG Blog
SEPTEMBER 18, 2024
Compensatory enlargement was defined as being present when the total coronary arterial cross-sectional area at the stenotic site was greater than that at the proximal nonstenotic site. Thus, the lumen observed may actually still be the same size as the original, normal lumen. Unfortunately, vascular remodeling is variable and inconsistent.
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ECG Cases 4: Lateral STEMI or Occlusion MI?
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
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Acute OMI or "Benign" Early Repolarization?
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. Guagliumi, G., Iwaoka, R.
E-9-1-1 117
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What does the angiogram show? The Echo? The CT coronary angiogram? How do you explain this?
Dr. Smith's ECG Blog
NOVEMBER 15, 2023
Angiogram No obstructive epicardial coronary artery disease Cannot exclude non-ACS causes of troponin elevation including coronary vasospasm, stress cardiomyopathy, microvascular disease, etc. CORONARY ARTERIES: Exam was not directly tailored for coronary artery evaluation, noting recent diagnostic coronary angiogram.
Coronary 100
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OMI in a pediatric patient? Teenagers do get acute coronary occlusion, so don't automatically dismiss the idea.
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
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Early repol or anterior OMI?
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.
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Cath Lab occupied. Which patient should go now (or does only one need it? Or neither?)
Dr. Smith's ECG Blog
OCTOBER 15, 2024
Additionally, his cardiac telemetry monitor showed runs of accelerated idioventricular rhythm, a benign arrhythmia often associated with coronary reperfusion. The patient is a 75-year old man with known coronary disease, including prior LAD and LCx OMI. That this patient has severe underlying coronary disease is indisputable.
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SGEM#234: Contrast Induced Nephropathy – A Unicorn?
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. It came out of case reports and non-controlled studies.
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Normal angiogram one week prior. Must be myocarditis then?
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.
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Clinical Conundrum: Should a Troponin Routinely be Ordered in Patients with SVT?
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.
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ECG Cases 13: LVH and Occlusion MI
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.
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The Bleeding Heart
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
130 
Expert human ECG interpretation and/or the Queen of Hearts could have saved this patient's anterior wall
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.
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Resuscitated from ventricular fibrillation. Should the cath lab be activated?
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.
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The CT FIRST Trial: Should We Pan-CT After ROSC?
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.
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REBEL Core Cast 111.0 – Cardiac Testing
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.
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Is OMI an ECG Diagnosis?
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?
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This ECG was texted to me: normal variant early repolarization, or LAD Occlusion MI (OMI)?
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.
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A 50-something with Regular Wide Complex Tachycardia: What to do if electrical cardioversion does not work?
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?
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Quiz post: 2 similar patients with similar ECGs. Which, if any, or both, are OMI? Will you outperform the Queen of Hearts?
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.
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The ECLS-SHOCK Trial: ECPR in Infarct-Related Cardiogenic Shock
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 136
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Chest pain, resolved. Does it need emergent cath lab activation (some controversy here)? And much much more.
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.
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See what happens when a left main thrombus evolves from subtotal occlusion to total occlusion.
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!
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Concerning EKG with a Non-obstructive angiogram. What happened?
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.
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SGEM#326: The SALSA Study: Hypertonic Saline to Treat Hyponatremia
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.
A 29 year old male with chest pain, ST Elevation, and very elevated troponin T
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.
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Occlusion myocardial infarction is a clinical diagnosis
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.
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An undergraduate who is an EKG tech sees something. The computer calls it completely normal. How about the physicians?
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.
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Acute artery occlusion -- which one?
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?
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Torsade in a patient with left bundle branch block: is there a long QT? (And: Left Bundle Pacing).
Dr. Smith's ECG Blog
JANUARY 2, 2025
Among patients with left bundle branch block, T-wave peak to T-wave end time is prolonged in the presence of acute coronary occlusion. Finally, do a coronary angiogram Possible alternative to pacing is to give a beta-1 agonist to increase heart rate. T-waves are quite tall and possibly peaked (HyperK?), but potassium returned normal.
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How terrible can it be to fail to recognize OMI? To whom is OMI Obvious or Not Obvious?
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 ).
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STREAM-2: Half-Dose Tenecteplase vs Primary PCI in Older Patients with STEMI?
REBEL EM
SEPTEMBER 28, 2023
STREAM-2: Half-Dose Tenecteplase or Primary Percutaneous Coronary Intervention in Older Patients With ST-Segment-Elevation Myocardial Infarction: A Randomized, Open-Label Trial. Based on this, the authors did a literature review and found that there is an increasing rate of ICH and major non-intracranial bleeding starting at ≈60 years of age.
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The Computer and Overreading Cardiologist call this completely normal. Is it?
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
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Lecture by Smith: Selected Cases of Occlusion MI (OMI), or not, on the ECG
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.
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VF arrest at home, no memory of chest pain. Angiography non-diagnostic. Does this patient need an ICD? You need all the ECGs to know for sure.
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
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Healthy 45-year-old with chest pain: early repolarization, pericarditis or injury?
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.
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50 year-old in remote rural community with chest pain and ‘normal’ ECG
Dr. Smith's ECG Blog
SEPTEMBER 8, 2023
As per Dr. McLaren — today's patient was lucky in that the acute coronary occlusion spontaneously reperfused — and the patient remained pain-free. There’s clear T wave inversion in III/aVF, which is reciprocal to subtle ST elevation and hyperacute T waves in I/aVL (broad, symmetric, and larger than the entire QRS in aVL).
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ECG Pointers: STEMI Equivalents from the American College of Cardiology
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.”
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A 30-something with acute chest pain
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?
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Acute chest pain in a patient with LVH and known coronary disease. What does the ECG show?
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 79
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"A patient just arrived as a transfer for NSTEMI."
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.
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Coronary Angiography Guide by Willy Frick -- Everything you ever wanted to know about the Cath Lab
Dr. Smith's ECG Blog
NOVEMBER 25, 2024
Introductory Angiography Guide To find the guide later, go to the banner at the top of the blog: This blog is dedicated to improving understanding of ECGs in the context of emergency medicine. Introductory Angiography Guide I wrote the entire guide to help readers understand angiographic images I post on the blog in more depth.
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What are treatment options for this rhythm, when all else fails?
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.
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