Core EM

JANUARY 25, 2024

Differentiating between the two is difficult as multiple proposed diagnostic criteria have yet to demonstrate sufficient sensitivity or specificity for a definitive diagnosis. Risk factors that increase the likelihood of VT include history of previous myocardial infarction, known coronary artery disease, and structural heart disease.

Coronary 246

Coronary Emergency Department ED OR 246

Dr. Smith's ECG Blog

OCTOBER 22, 2024

The coronary angiography showed a 100% ostial main (obtuse) marginal occlusion!" Dominant right coronary, atherosclerotic and calcified. Presence of a single coronary lesion: occlusion of the ostial main marginal. ECG #1 — shows such subtle but-definitely-present changes in multiple leads: The rhythm is sinus at 80-85/minute.

Coronary 66

Coronary STEMI OR ALS 66

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 110

STEMI Coronary Emergency Department OR 110

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. Definitive diagnosis that ECG #1 is in fact VT is more than academic.

Coronary 136

Coronary OR EMS ED 136

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.

STEMI 101

STEMI Coronary ACS ED 101

Dr. Smith's ECG Blog

OCTOBER 24, 2018

Therefore, this does not meet the definition of myocardial infarction ( 4th Universal Definition of MI ), which requires at least one troponin above the 99% reference range. You can see the deficiency of the definition of MI. Two negative troponins do not exclude the possibility of short-lived acute coronary occlusion.

E-9-1-1 52

E-9-1-1 STEMI ACS Coronary 52

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

The Skeptics' Guide to EM

OCTOBER 20, 2018

The acute coronary syndrome work-up is negative but she is Well’s high and needs a CTPA to rule-out a pulmonary embolism. Part of the difficulty with this topic is the inconsistent definition of contrast-induced nephropathy. A common definition is an increase in creatinine level by 25% or an absolute increase of 0.3

Coronary 174

Coronary Emergency Department ALS OR 174

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 ). Answer: This is MINOCA -- Myocardial Infarction with Non-Obstructive Coronary Arteries. His troponin peaked at 10.310 ng/mL and trended down. The name is self-explanatory.

Coronary 71

Coronary OR 71

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]. In an attempt to clarify language, a consensus definition was developed. per 100,000 to 11 per 100,000 [Rosso].

E-9-1-1 116

E-9-1-1 OR Coronary ACS 116

Dr. Smith's ECG Blog

JUNE 15, 2023

Thus, this does NOT meet STEMI criteria (though, as of 2022, it is a formal "STEMI equivalent", assuming everyone agrees that this is de Winter morphology, for which there is currently no objective definition). Even if a patient's ECG does meet STEMI criteria, it may not be perceived so. What a farce.

STEMI 93

STEMI Coronary ACS OR 93

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 ).

E-9-1-1 109

E-9-1-1 Coronary STEMI ALS 109

Dr. Smith's ECG Blog

SEPTEMBER 29, 2024

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. See Discussion in the June 29, 2024 post of Dr. Smith' ECG Blog ). The April 8, 2022 post by Drs.

STEMI 80

STEMI Coronary Defibrillator OR 80

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-9-1-1 118

E-9-1-1 Coronary ACS BLS 118

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. This is another case sent by the undergraduate (who is applying to med school) who works as an EKG tech. No ECG was ordered on Day #1.

Coronary 108

Coronary STEMI Emergency Department OR 108

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

More past history: hypertension, tobacco use, coronary artery disease with two vessel PCI to the right coronary artery and circumflex artery several years prior. Suppose the OMI had been recognized, or suppose another ECG had been recorded and it showed definite OMI. It is unknown when this pain recurred and became constant.

Defibrillator 130

Defibrillator Coronary STEMI CPR 130

Dr. Smith's ECG Blog

DECEMBER 22, 2022

Smith , d and Muzaffer Değertekin a DIFOCCULT: DIagnostic accuracy oF electrocardiogram for acute coronary OCClUsion resuLTing in myocardial infarction. Coronary arteries cannot be assessed because the scan was not gated, but proximal segments of the coronary arteries seem to be open with some contrast. Again nothing diagnostic.

STEMI 52

STEMI EMR Coronary OR 52

Dr. Smith's ECG Blog

SEPTEMBER 22, 2023

What lowered my confidence in calling ECG #1 a definite OMI — was the finding of somewhat similar-appearing , upright T waves with slight-but-real J-point ST elevation in so many leads ( ie, leads I,II,aVF; V2-thru-V6 ). Once I identified leads V4 and V5 as definitely abnormal — I looked closer at neighboring leads.

OR 123

OR STEMI Coronary 123

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

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. Such cases are classified as MINOCA (Myocardial Infarction with Non-Obstructed Coronary Arteries). It can only be seen by IVUS.

Emergency Department 52

Emergency Department E-9-1-1 Coronary STEMI 52

Dr. Smith's ECG Blog

AUGUST 6, 2024

It definitely does not fulfill STEMI criteria, and I would argue that it would not lead to cath lab activation in most centers. All coronary arteries were patent without atherosclerotic change. Only after troponin returned elevated was an Echo was done, revealing a definite wall motion abnormality.

Coronary 85

Coronary OR STEMI EMS 85

Dr. Smith's ECG Blog

MARCH 1, 2023

It is unclear to me whether this case could represent 1) simple supply/demand mismatch due to increased demand from epinephrine, 2) Kounis syndrome (usually described as mast cell mediated coronary vasospasm during allergic reaction), 3) brief autolysed left main or LAD ACS with no findings on later echo and CT coronary angio, or 4) something else.

Allergic Reaction 52

Allergic Reaction E-9-1-1 Epinephrine Coronary 52

Dr. Smith's ECG Blog

OCTOBER 18, 2023

When I saw the ECG of this patient I saw that there was definitely something "off". The patient was referred for coronary angiography which did not reveal any atherosclerotic changes. A formal echo at the PCI center after coronary angiography revealed a large septal and apical WMA. Troponin I peaked at 769 ng/L.

Defibrillator 104

Defibrillator Advanced Life Support Coronary Life Support 104

REBEL EM

MARCH 2, 2023

Background: Historically, we have treated acute coronary syndrome with supplemental oxygen regardless of the patient ’ s oxygen saturation. More recent evidence, however, demonstrates that too much oxygen could be harmful ( AVOID Trial ) by causing coronary vasoconstriction and increasing oxidative stress. Low O2 protocol: 3.1%

ACS 52

ACS Coronary STEMI Ambulance 52

Dr. Smith's ECG Blog

JUNE 11, 2024

Finally — there is the clinical reality that a patient who has a "baseline" ECG that manifests a repolarization variant — may at some point develop acute coronary occlusion that in part is masked by benign-appearing ECG characteristics of the underlying repolarization variant. It is clearly missed by the conventional algorithm.

STEMI 111

STEMI Coronary Emergency Department OR 111

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. 1, 2] The most clinically useful definition to account for this entire constellation is intraventricular conduction delay. Attached is the first ECG. Isn’t VT ALWAYS “wide”?

ALS 130

ALS STEMI Coronary OR 130

Dr. Smith's ECG Blog

JULY 2, 2023

A delta of 3 ng/L definitely would not rule-in MI for any assay, but it does raise the possibility that further measurements would result in a 4- or 6-hour troponin above the URL and thus make the diagnosis of acute MI. We don't know if he had a stress test, a CT Coronary angiogram, or they just decided to do an angiogram.

ACS 52

ACS Coronary OR 52

Dr. Smith's ECG Blog

OCTOBER 30, 2024

However, there was no thrombotic component and there was TIMI III flow in all coronaries and their main branches. A CT scan was done as part of the work up, but no definite cause of the patient's chest pain was identified. And, even if there was acute aortic dissection — the dissection could result in occlusion of a coronary artery.

Coronary 89

Coronary EMS OR STEMI 89

Dr. Smith's ECG Blog

JULY 31, 2020

Yet despite this remarkable flaw in the STEMI-paradigm — a substantial number ( if not a frank majority ) of clinicians continue to apply outdated criteria when interpreting ECGs, by refusing to consider prompt cath for definitive diagnosis and reperfusion therapy just because a millimeter-based definition for acute STEMI is not satisfied.

STEMI 52

STEMI Coronary EMR ALS 52

Dr. Smith's ECG Blog

AUGUST 9, 2024

Serial ECGs enhance the diagnosis of acute coronary syndrome. Although recognition of OMI was not affected by administration of morphine in this case, use caution with analgesia in ongoing ACS without a definitive plan for angiography. Although tiny in size — the BLUE arrows highlight definite ST elevation in leads I and aVL.

STEMI 84

STEMI Coronary Heart Attack ACS 84

EMDocs

JULY 1, 2023

Upon further research in the 1970’s, retrospective data from autopsies of those patients showed coronary aneurysms 5 Pathophysiology: Kawasaki Disease is a vasculitis of medium sized arteries. Tomisaku Kawasaki, who noticed 50+ similar pediatric presentations between the years 1961 and 1967.

EMS 66

EMS Coronary ED OR 66

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. Serial tracings often show “ dynamic ” ST-T wave changes — which in a patient with CP, allow prompt definitive diagnosis that might not have been obvious with just a single tracing.

STEMI 79

STEMI Coronary Ambulance ED 79

Dr. Smith's ECG Blog

JANUARY 8, 2024

She went to angio and had normal coronaries. No d-dimer or CT pulmonary angiogram was done when they discovered that she had normal coronary arteries. Think of this diagnosis when a patient with CP and SOB + elevated troponin — has normal coronary arteries on cardiac cath. I discussed all results with patient.

Coronary 71

Coronary STEMI EMS OR 71

Dr. Smith's ECG Blog

APRIL 25, 2023

But the stuttering pain and sudden onset suggest acute coronary occlusion (Occlusion MI, or OMI). Cath lab activation by the ED and I agree with coronary angiography emergently." Result: no angiographically significant obstructive coronary artery disease. Smith and Meyers to diagnose both obvious (STEMI) and subtle OMI.

Coronary 52

Coronary STEMI ALS OR 52

Dr. Smith's ECG Blog

JANUARY 9, 2024

However , this patient is having chest discomfort, and by definition then she should be considered not to be stable. The patient is an older woman with known coronary disease and an ICD-Pacemaker implanted because of a history of VT ( V entricular T achycardia ). Is this: 1. Figure-1: I have labeled the initial ECG in today's case. (

Coronary 98

Coronary ACS ED OR 98

Dr. Smith's ECG Blog

NOVEMBER 22, 2023

Angiogram: Severe two-vessel coronary artery disease with possible co-culprits (90% proximal circumflex, 70% mid/distal RCA) in the setting of non-ST elevation myocardial infarction. Marked ST depression from multi-vessel coronary disease serves to attentuate what would have been ST elevation in leads II and aVF ).

ED 102

ED Coronary CAD STEMI 102

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. There is no definite evidence of acute ischemia. (ie,

Defibrillator 113

Defibrillator Coronary ALS STEMI 113

Dr. Smith's ECG Blog

AUGUST 20, 2024

Record serial ECGs == MY Comment , by K EN G RAUER, MD ( 8/16 /2024 ): == It is always a challenge to interpret an ECGs from a patient with known coronary disease, but no prior tracing for comparison. Given the known history of coronary disease — multiple previous ECGs certainly were done. Use the Queen of Hearts 2.

Coronary 64

Coronary OR 64