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 138

Coronary OR EMS ED 138

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 104

STEMI Coronary ACS ED 104

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 93

Coronary CAD ACS OR 93

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 75

Coronary OR 75

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 171

Coronary Emergency Department ALS OR 171

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 92

STEMI Coronary ACS OR 92

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-9-1-1 122

E-9-1-1 Coronary ACS BLS 122

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 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 133

Defibrillator Coronary STEMI CPR 133

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 126

OR STEMI Coronary 126

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 107

Defibrillator Advanced Life Support Coronary Life Support 107

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 88

STEMI Coronary Heart Attack ACS 88

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

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

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 67

Coronary OR 67

Dr. Smith's ECG Blog

SEPTEMBER 11, 2024

The initial ECG in today's case was recognized as definitely abnormal — but the question arose as to whether this ECG indicated old infarction vs a new acute event. The "good news" — is that a cardiac-related cause of syncope is unlikely if the initial ECG is normal, and cardiac monitoring in the ED fails to reveal significant arrhythmia.

EMS 107

EMS CPR ED Coronary 107

EMDocs

SEPTEMBER 7, 2024

A 70-year-old female with a past medical history of hypertension, coronary artery disease s/p 2x drug eluting stent placement one month ago, atrial fibrillation on apixaban presents to the ED with weakness and lightheadedness. Additionally, no current high-quality literature exists regarding the definitive indications for REBOA placement.

EMS 73

EMS E-9-1-1 Operating Room OR 73

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

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 116

Defibrillator Coronary ALS STEMI 116

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

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

MAY 19, 2020

Angiography showed normal coronaries. A followup ECG was recorded 2 days later: No definite evidence of infarction. MINOCA: Myocardial Infarction in the Absence of Obstructive Coronary Artery Disease). Here is my comment on MINOCA: "Non-obstructive coronary disease" does not necessarily imply "no plaque rupture with thrombus."

Defibrillator 52

Defibrillator CPR Coronary CAD 52

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

When Pendell and I are coding ECGs for the Queen's training, this is one category: "Definite ischemia, difficult to differentiate between posterior OMI and subendocardial ischemia." The De Winter ECG pattern: morphology and accuracy for diagnosing acute coronary occlusion: systematic review. 2009;95:1701–1706. Morris N, Body R.

ACS 87

ACS Coronary ALS CAD 87

Dr. Smith's ECG Blog

APRIL 4, 2023

Fortunately, Dr. Cho was not looking for STEMI ECG criteria but for an acute coronary occlusion. As he documented, “This patient is experiencing chest pain consistent with an acute coronary syndrome. Start using the terms acute coronary occlusion and occlusion MI.

STEMI 52

STEMI Coronary OR ACS 52

EMS 12-Lead

AUGUST 22, 2022

They are not premature, by definition. The coronary angiogram revealed no critical stenosis, or acute plaque ulceration. Takotsubo should be a diagnosis of exclusion after angiography reveals no obstructive coronary disease, and repeat Echo displays left ventricular recovery. Furthermore, pertinent electrolyte values (e.g.

E-9-1-1 130

E-9-1-1 Coronary ALS ICU 130

Dr. Smith's ECG Blog

OCTOBER 12, 2023

There is maybe no definite answer and arguments can be made for the different scenarios. An MRi was not done for this patient and a definite answer maybe cannot be obtained. with the important message that sometimes ( especially in retrospect! ) — a definite diagnosis can not be made. There is reconstitution of R waves V3-V6.

Coronary 105

Coronary OR ED 105

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. The Need for Immediate Transport? Limb lead findings in ECG #2 look more hyperacute than they did in ECG #1 — because of subtle-but-real increased ST segment straightening in leads I, III and aVL.

OR 131

OR STEMI Coronary Emergency Department 131

Dr. Smith's ECG Blog

MAY 8, 2023

Electrocardiographic Diagnosis of Acute Coronary Occlusion Myocardial Infarction in Ventricular Paced Rhythm Using the Modified Sgarbossa Criteria. Immediate ECG diagnosis of an acute coronary lesion resulting in occlusion myocardial infarction is critical in the modern reperfusion era. Annals of Emergency Medicine 2021.

STEMI 52

STEMI Coronary ED ACS 52

Dr. Smith's ECG Blog

MARCH 13, 2024

Distilling this case into its most salient components, a man with multiple risk factors for coronary disease is presenting with several days of chest pain and markedly elevated troponin with no other reason to explain the lab abnormality ( e.g. sepsis). High sensitivity troponin I (hsTnI) obtained around that time was 5548 ng/L (ref. <

Coronary 89

Coronary ACS Emergency Management Emergency Manager 89

Dr. Smith's ECG Blog

JULY 16, 2022

This illustration comes from Charles Bruen's great blog, Resus Review Coronary Artery Diagramming – Resus Review Charles is another illustrious graduate of the Hennepin EM Residency; actually, the EM/IM combined residency. These features are subtle — but they are definitely present and important to recognize.

Coronary 52

Coronary ED EMS Critical Care 52

Dr. Smith's ECG Blog

MAY 23, 2023

I have here 38 cases of "Computer Normal" ECGs which were critically abnormal and the vast majority are missed acute coronary occlusions (Missed Acute OMI) and most were recognized by the physician. Of the Non-STEMI in our cohort, about 25% will actually have acute coronary occlusion. So this study is worthless and must be ignored.

STEMI 88

STEMI Coronary Paramedic OR 88

Dr. Smith's ECG Blog

NOVEMBER 14, 2023

We who know ischemic ECGs know that really when T-wave inversion is specific for coronary thrombosis that it indicates reperfusion of the artery, not active occlusion. that is, show a pattern of labile ST-T wave changes not due to an acute coronary event. I personally can hardly wait for that future version! Some patients do this.

E-9-1-1 110

E-9-1-1 Coronary EMS ED 110

Dr. Smith's ECG Blog

MARCH 31, 2023

It is definitely not normal. The 2 clinical areas of most potential benefit to emergency care from computerized interpretations are: i ) Cardiac arrhythmias; and , ii ) Rapid detection of acute coronary O cclusion ( ie, detection of acute O MI ) in cases for which easily recognizable STEMI-criteria are not present.

STEMI 52

STEMI Coronary OR ED 52

Dr. Smith's ECG Blog

APRIL 21, 2023

But STEMI criteria has poor sensitivity for acute coronary occlusion. Like the initial hemoglobin level in acute hemorrhage, the initial troponin in acute coronary occlusion can be falsely reassuring. Smith : the definition of MI is based on clinical criteria and troponin.

STEMI 52

STEMI Coronary EMR OR 52

Dr. Smith's ECG Blog

MARCH 9, 2023

Hyperacute T waves do not yet have a formal research definition, but are likely defined best by an increased ratio of area under the curve compared to their QRS complex. Relationship between an in-farct related artery, acute total coronary occlusion, and mortality in patients with ST-segment and non-ST-segment myocardial infarction.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52