Dr. Smith's ECG Blog

SEPTEMBER 19, 2023

Past medical history includes coronary stenting 17 years prior. Initial ED ECG: What do you think? Cardiology was consulted and the patient underwent coronary angiogram which showed diffuse severe three-vessel disease. Coronary angiogram shows diffuse severe three-vessel disease.

Coronary 139

Coronary OR EMS ED 139

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]. Cardiology consult note written around that time documents that "Pain improved with NTG, morphine in ED but still present."

E-9-1-1 131

E-9-1-1 OR Coronary ACS 131

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 135

Defibrillator Coronary STEMI CPR 135

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

JUNE 5, 2023

Here is his initial ED ECG: What do you think? Then the ED doc would be dependent on that first ECG. It must have re-occluded between the ED and the cath lab) --Lesion was stented. Aside on ECG Research: 20% of Definite diagnostic STEMI (Cox et al.) have perfect coronary flow by the time of angiogram.

STEMI 96

STEMI Coronary ED Ambulance 96

EMDocs

JULY 1, 2023

A 3-year-old male with no past medical history presents to the ED with one week of daily fevers >102°F associated with four days of rash on the trunk. We’ll keep it short, while you keep that EM brain sharp. Tomisaku Kawasaki, who noticed 50+ similar pediatric presentations between the years 1961 and 1967. C) for the past week.

EMS 94

EMS Coronary ED OR 94

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

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-9-1-1 128

E-9-1-1 Coronary STEMI ALS 128

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-9-1-1 127

E-9-1-1 Coronary ACS BLS 127

Dr. Smith's ECG Blog

MAY 3, 2024

But this time the Queen gets it wrong (thinks it is not OMI): There were runs of VT: Tha patient arrived in profound shock and had an ED ECG: Now there is some evolution to include the ST elevation (rather than ST depression) in V4-V6. Figure-1: I've labeled the initial EMS ECG and the 1st 12-lead tracing done on arrival in the ED.

ACS 127

ACS ED Coronary EMS 127

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 119

Coronary ACS ED OR 119

Dr. Smith's ECG Blog

SEPTEMBER 29, 2024

On arrival to the ED, this ECG was recorded: What do you think? 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. This prompted cath lab activation.

STEMI 110

STEMI Coronary Defibrillator OR 110

EMS 12-Lead

MAY 8, 2022

They are definitely high in amplitude and, intermittently, appear to disproportionately tower over the respective QRS. This is critical for the EMS provider, or ED clinician, as identification of Grade I ischemia (aka, HATW’s) addresses the culprit lesion at the earliest opportunity with excellent downstream prognosis for the patient. [2]

STEMI 130

STEMI ED EMS Firefighter 130

Dr. Smith's ECG Blog

SEPTEMBER 11, 2024

When the patient arrived in the ED, he was still hypotensive in 70s, slowly improving with EMS fluids. Here is the ED ECG (a photo of the paper printout) What do you think? 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.

EMS 114

EMS CPR ED Coronary 114

ACEP Now

JULY 7, 2023

emergency departments (EDs), with statistics reporting more than 356,000 out-of-hospital cardiac arrests per year. Coronary artery disease in patients with out-of-hospital refractory ventricular fibrillation cardiac arrest. Out-of-hospital cardiac arrest is a commonly encountered entity in U.S. Circulation. 2019;139(12):e530-e552.

Defibrillator 98

Defibrillator OR ALS Epinephrine 98

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 120

Coronary STEMI Emergency Department OR 120

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 113

STEMI Coronary Emergency Department OR 113

Dr. Smith's ECG Blog

SEPTEMBER 6, 2011

He presented to the ED after 30 minutes, now also feeling weak. Thus, there are some suspicious abnormalities, but no definite signs of ischemia. But the definition misses the point. It is a coronary occlusion with a substantial myocardial territory at risk, that showed only very subtle ST changes. He was diaphoretic.

Coronary 52

Coronary STEMI ED OR 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

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. Here is the first ED ECG recorded, now pain free after sublingual Nitro: There is what appears to be a reperfusion T-wave in I and aVL. Some patients do this.

E-9-1-1 116

E-9-1-1 Coronary EMS ED 116

Dr. Smith's ECG Blog

NOVEMBER 29, 2023

Both cases had an EMS ECG that was transmitted to the ED physician asking "should we activate the cath lab?" On arrival to the ED, while waiting for cath lab team, he obtained another ECG: You can now see the full voltage of the high-voltage QRS, likely with some degree of LVH. Both were awake and alert with normal vital signs.

OR 125

OR STEMI EMS ED 125

EMS 12-Lead

APRIL 28, 2022

In most cases, rather, the culprit is gross ischemia due to myocardial infarction, cardiomyopathy, or advanced coronary artery disease. 4-6] In figures 1-4, specifically during the episodes of NSVT, there is a mostly regular cadence with preserved definition of both QRS and T. Chou’s Electrocardiography in Clinical Practice (6th ed).

E-9-1-1 130

E-9-1-1 ALS Coronary EMS 130

Dr. Smith's ECG Blog

SEPTEMBER 8, 2023

Keep in mind the presenting History ( ie, a 50yo presenting to a rural ED with a 1-hour history of CP radiating to the back and jaw — and an initial ECG labeled as "normal" by the computer interpretation ). As you comtemplate the above issues to address — Take another LOOK at these first 2 ECGs in today's case.

OR 130

OR STEMI Coronary Emergency Department 130

Dr. Smith's ECG Blog

OCTOBER 12, 2023

As part of her work up in the ED an ECG was recorded. 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. The patient is a 60 something female. She was febrile and hypotensive at presentation.

Coronary 111

Coronary OR ED 111

Dr. Smith's ECG Blog

MAY 23, 2023

But the paramedic and the ED physician in this case did not subscribe to this idea. 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. So this study is worthless and must be ignored.

STEMI 98

STEMI Coronary Paramedic OR 98

Dr. Smith's ECG Blog

MARCH 13, 2023

An ED ECG, if recorded with pain, should show LAD OMI. So this ECG was immediately recorded: Indeed, as predicted, a patient with previous Wellens' waves who now definitely has chest pain has acute Occlusion, with new ST elevation in I, aVL, V2-V5. The Cath lab was activated.

ED 52

ED ACS Coronary Paramedic 52

Dr. Smith's ECG Blog

OCTOBER 8, 2023

Imagine you just started your ED shift. Triage is backed up, and 10 minutes into your shift one of the ED nurses brings your several ECG s that has not been overread by a physician. R wave V4 9mm) C T of the coronary arteries showed no lesions. That said, this patient did present to the ED with "new CP" — and.

ED 123

ED Coronary OR 123

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. A 25-year-old man presents to the ED via EMS after he sustained a gunshot wound to the left flank.

EMS 98

EMS E-9-1-1 Operating Room OR 98

Dr. Smith's ECG Blog

OCTOBER 22, 2024

He reported typical chest pain since 4H AM and arrived at our ED at 10h with ongoing chest pain. 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.

Coronary 66

Coronary STEMI OR ALS 66

Dr. Smith's ECG Blog

DECEMBER 9, 2023

On arrival in the ED, the patient denied any symptoms at all. No chest pain, no shortness of breath, no back pain, no numbness, weakness, tingling, no seizures or history of seizures, First ED ECG This still shows apparent inferior OMI. The patient was g iven full dose aspirin and the medics activated the Cath Lab.

STEMI 115

STEMI Coronary ED Paramedic 115

Dr. Smith's ECG Blog

MARCH 1, 2023

Sent by anonymous, written by Pendell Meyers A man in his late 40s presented to the ED with concern for allergic reaction after accidentally eating a potential allergen, then developing an itchy full body rash and diarrhea. In the ED he received methylprednisolone, diphenhydramine, and epinephrine for possible anaphylaxis.

Allergic Reaction 52

Allergic Reaction E-9-1-1 Epinephrine Coronary 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

SEPTEMBER 29, 2023

Sent by anonymous, written by Pendell Meyers, reviewed by Smith and Grauer A man in his 40s presented to the ED with HTN, DM, and smoking history for evaluation of acute chest pain. The angiogram showed completely normal coronary arteries. Triage ECG: What do you think? Note that the Tp is oppositely directed to the P wave.

STEMI 130

STEMI ED OR Coronary 130

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

A man in his 70s with past medical history of hypertension, dyslipidemia, CAD s/p left circumflex stent 2 years prior presented to the ED with worsening intermittent exertional chest pain relieved by rest. The De Winter ECG pattern: morphology and accuracy for diagnosing acute coronary occlusion: systematic review. 2009;95:1701–1706.

ACS 83

ACS Coronary ALS CAD 83

Dr. Smith's ECG Blog

OCTOBER 24, 2019

link] A 30 year-old woman was brought to the ED with chest pain. The biphasic T wave is consistent with recent reperfusion of an occluded coronary artery supplying the inferior region. Here’s the angiogram of the RCA : No thrombus or plaque rupture in the RCA (or any coronary artery) was found. This is written by Brooks Walsh.

Coronary 52

Coronary CAD ACS STEMI 52

Dr. Smith's ECG Blog

JANUARY 8, 2024

She went to angio and had normal coronaries. She was briefly resuscitated and made it to the ED alive, long enough to have another ECG: This could be all due to RV strain or the STE in inferor leads could also be due to supply demand mismatch (type II STEMI) She was given 100 mg of tPA but arrested again and could not be resuscitated.

Coronary 71

Coronary STEMI EMS Paramedic 71

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