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 101

Coronary E-9-1-1 STEMI ACS 101

EMergucate

JUNE 7, 2023

Myocardial infarction with non-obstructive coronary arteries: what is the prognosis? Giampaolo Niccoli1,2 and Paolo G. Camici3* 1Universita’ Cattolica del Sacro … Continue reading →

Coronary 100

Coronary 100

St. Emlyn's

JULY 3, 2024

FOAMed The post Systematic review of the Manchester Acute Coronary Scores. St.Emlyn's - Emergency Medicine #FOAMed Journal Club on the impact of the MACS score in emergency medicine (systematic review). Learn how this tool improves diagnosis and patient outcomes while optimising hospital resources."FOAMed

Coronary 52

Coronary 52

Dr. Smith's ECG Blog

DECEMBER 5, 2023

Beyond STEMI: Diagnosing Acute Coronary Occlusion on the ECG. The Queen of Hearts AI app can do it for you. With explainability too.

Coronary 128

Coronary STEMI 128

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 60

Coronary ALS 60

The Skeptics' Guide to EM

JULY 2, 2022

Major adverse cardiac event rates in moderate-risk patients: Does prior coronary disease matter? Major adverse cardiac event rates in moderate-risk patients: Does prior coronary disease matter? He has no history of coronary artery disease. Date: June 30th, 2022 Reference: McGinnis et al. AEM June 2022. AEM June 2022.

Coronary 100

Coronary Heart Attack ACS CAD 100

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

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

CanadiEM

NOVEMBER 7, 2023

For the October 2023 issue of CJEM, we collaborated with their team to present “Machine learning for the diagnosis of acute coronary syndrome using a 12-lead ECG: a systematic review”​1​​ in a visually simplified format. We often rely on our clinicians interpretation of the 12-lead, instead.

Coronary 52

Coronary OR 52

ALiEM

FEBRUARY 9, 2024

Intermediate-risk patients may be further stratified based on recent stress testing or coronary angiogram findings plus a modified HEART or Emergency Department Assessment of Chest Pain (EDACS) score. The patient has no previous stress testing or coronary angiogram, and he is not low risk by HEART or EDACS scoring.

E-9-1-1 276

E-9-1-1 ED Coronary ALS 276

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

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

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 106

Coronary ACS ALS OR 106

Emergency Medicine Cases

SEPTEMBER 12, 2023

Jesse MacLaren guides us through 10 cases of patients who present with generalized weakness or acute neurologic symptoms and discusses how to look for ECG signs of dysrhythmias, electrolyte emergencies, acute coronary occlusion, and demand ischemia in patients with generalized weakness and in patients with neurologic symptoms, to consider predisposing (..)

Coronary 296

Coronary OR EMS 296

Core EM

JULY 23, 2024

Isolated posterior MI is less common (3-8% of OMI) and presents with isolated ST-depressions in the anterior precordial leads (V1-V4), representing reciprocal changes to posterior left ventricular wall myocardial infarction as a result of distal occlusion of either the left circumflex or right coronary artery.

STEMI 173

STEMI Coronary Emergency Department OR 173

EMS 12-Lead

APRIL 9, 2024

There is increased LV cavity dimensions with an increase in transient ischemic dilation, suggesting Left Main, or 3-vessel coronary artery disease. 2. Coronary angiography reveals significant and severe CAD involving all three epicardial vessels. Strongly positive stress ECG Lexiscan administration. He was taken to the Cath Lab.

Coronary 290

Coronary ACS CAD ED 290

Core EM

NOVEMBER 15, 2023

The Case A 62-year-old male with a history of Hypertension, Hyperlipidemia, Coronary Artery Disease with stents, Pulmonary Embolism on Eliquis, presents with sudden onset, severe, mid-sternal chest pain that started 15 minutes prior to arrival. Discussion Case Discussion: The patient’s history was concerning for an acute coronary syndrome.

Coronary 130

Coronary STEMI ED 130

Emergency Medicine Cases

JUNE 18, 2024

In this month's EM Quick Hits podcast: Megan Landes on the importance of diagnosing HIV in the ED, Jesse McLaren on the failed paradigm of STEMI criteria and ECG tips to identify acute coronary occlusion, Anand Swaminathan on evidence for non-invasive airway management in the poisoned patient, Brit Long and Hans Rosenberg on the identification, workup (..)

STEMI 169

STEMI EMS Coronary ED 169

Emergency Medicine Cases

DECEMBER 20, 2023

ST/T changes: consider the differential including demand ischemia, associated electrolyte abnormalities, Brugada pattern from sodium channel blockade, and acute coronary occlusion vs vasospasm from cocaine. The post ECG Cases 47 – ECG Interpretation in Toxicology appeared first on Emergency Medicine Cases.

Coronary 207

Coronary OR Overdose EMS 207

EMS 12-Lead

JULY 24, 2023

Category 1 : Sudden narrowing of a coronary artery due to ACS (plaque rupture with thrombosis and/or downstream showering of platelet-fibrin aggregates. It’s judicious, then, to arrange for coronary angiogram. Supply-demand mismatch (non-occlusive coronary disease, or exacerbation of preexisting flow insufficiency) a.

Coronary 130

Coronary ACS CAD ED 130

The Skeptics' Guide to EM

NOVEMBER 25, 2023

A 12-lead electrocardiogram (ECG) demonstrates ST elevations in leads II, III, and aVF with ST depressions in leads I and aVL and the team begins transport to the nearest percutaneous coronary intervention (PCI) capable hospital. Background: We have covered the issue of heart attacks several times on the SGEM. Reference: Stopyra et al.

Heart Attack 278

Heart Attack STEMI Emergency Medical Services Coronary 278

EMergucate

JANUARY 10, 2023

The following ECG was obtained from a 61 year old man with coronary artery disease and previous coronary stents. Please … Continue reading →

Coronary 130

Coronary EMS 130

Dr. Smith's ECG Blog

AUGUST 9, 2019

Post by Smith and Meyers Sam Ghali ( [link] ) just asked me (Smith): "Steve, do left main coronary artery *occlusions* (actual ones with transmural ischemia) have ST Depression or ST Elevation in aVR?" Furthermore, among 35 patients with acute left main coronary artery occlusion, 9 presented with RBBB (mostly with LAFB) on the admission ECG.

Coronary 52

Coronary STEMI ACS ALS 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

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

NOVEMBER 14, 2024

The patient is a 54yo man with diabetes and a known history of coronary diseae ( prior stent placement ) — who presented with new CP ( C hest P ain ) — therefore very high likelihood for having an acute coronary event.

ED 116

ED Coronary Paramedic OR 116

Core EM

FEBRUARY 23, 2024

Isolated posterior MI is less common (3-8% of OMI) and presents with isolated ST-depressions in the anterior precordial leads (V1-V4), representing reciprocal changes to posterior left ventricular wall myocardial infarction as a result of distal occlusion of either the left circumflex or right coronary artery.

STEMI 130

STEMI Coronary Emergency Department OR 130

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. 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. And what do you want to do?

Defibrillator 110

Defibrillator Coronary ACS Epinephrine 110

EMergucate

NOVEMBER 28, 2022

She thinks she may have had stenting to her coronaries but … A 52 year old woman is triaged as a category 2 after complaining of chest tightness on the background of having previous cardiac history.

Coronary 130

Coronary 130

The Bottom Line

OCTOBER 13, 2024

2024.17888 Clinical Question In adult patients undergoing coronary artery bypass surgery (CABG) is supplementing potassium when serum concentration is ≤ 3.5 Potassium Supplementation and Prevention of Atrial Fibrillation After Cardiac Surgery: The TIGHT K Randomized Clinical Trial O’Brien. JAMA 2024; 332:979 – 988.

Coronary 68

Coronary 68

EMS 12-Lead

SEPTEMBER 6, 2022

Coronary thrombosis is a dynamic process of platelet aggregation and subsequent coagulation. During spontaneous reperfusion -- whether via thrombolysis, or recruitment of collateral circulation -- there exists characteristic ST/T changes on the ECG. Case Review: [link]

Coronary 130

Coronary OR 130

EMS 12-Lead

AUGUST 18, 2024

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. Here is the ECG after 200J. Readers of the Smith ECG Blog will probably recognize this a very subtle inferior OMI.

CAD 147

CAD EMT EMT ACS 147

Dr. Smith's ECG Blog

SEPTEMBER 1, 2024

Abstract of QOH Retrospective Data by Willy Frick MD et al.

Coronary 52

Coronary ALS 52

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 117

STEMI Coronary ALS CAD 117

EMS 12-Lead

MAY 20, 2022

Additional architectural changes include systolic anterior motion of the mitral valve, endothelial dysfunction at the level of the coronary arterial bed, and ventricular diastolic dysfunction. This worried the crew of potential acute coronary syndrome and STEMI was activated pre-hospital. It is spread to V2 and V3. References Naidu, S.

Coronary 130

Coronary STEMI Firefighter ED 130

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

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