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

OCTOBER 12, 2024

The providers documented concern for ST elevation in the precordial and lateral leads as well as a concern for hyperkalemic T waves in the setting of succinylcholine administration. Preliminary findings documented in the cath lab were “Anterior STEMI and no significant coronary artery disease.” (!!!) Potassium resulted as 4.9,

STEMI 116

STEMI Coronary Emergency Department ACS 116

Dr. Smith's ECG Blog

JUNE 17, 2024

showed that among patients with either acute coronary syndrome or acute pulmonary embolism and negative T waves in the precordial leads (V1-V4), that inverted T waves in leads III and V1 were present in only 1% of patients with acute coronary syndrome and 88% of patients with pulmonary embolism. In fact, Kosuge et al.

E-9-1-1 139

E-9-1-1 ACS Emergency Department Coronary 139

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.

Defibrillator 131

Defibrillator Coronary ALS STEMI 131

Dr. Smith's ECG Blog

JANUARY 5, 2024

The documentation does not describe any additional details of the history. They also documented "Reproducible chest tenderness." We know that even high-sensitivity troponin may not exceed the "normal" range for a period of hours in certain patients with acute coronary occlusion. The following ECG was obtained.

ACS 121

ACS ALS OR STEMI 121

Dr. Smith's ECG Blog

JANUARY 9, 2024

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 ). In this case report — the 69-year old woman ( who incidently had a history of both coronary disease and cardiomyopathy ) — remained in sustained VT for 5 days without hemodynamic deterioration.

Coronary 119

Coronary ACS ED OR 119

Dr. Smith's ECG Blog

SEPTEMBER 22, 2023

And you can see why: the artery may sponstaneously reperfuse, as it did here well before angiography, and documented with resolution of pain and evolution of the ECG to typical full reperfusion pattern Peak troponin I was 8544 ng/L. This is typical for a brief LAD OMI.

OR 131

OR STEMI Coronary 131

Dr. Smith's ECG Blog

NOVEMBER 15, 2013

It is well documented with continuous 12-lead monitoring that acute re-occlusion is frequently asymptomatic. It is important to recognize that coronary thrombosis is dynamic , with spontaneous opening and lysing of the thrombus in the infarct-related artery (we all have endogenous tPA and plasmin to lyse thrombi). Akkerhuis KM, et al.

Coronary 52

Coronary STEMI ALS Emergency Department 52

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.

OR 120

OR STEMI Heart Attack Coronary 120

Dr. Smith's ECG Blog

AUGUST 9, 2024

He had no previously documented medical problems except polysubstance use. Serial ECGs enhance the diagnosis of acute coronary syndrome. Association of intravenous morphine use and outcomes in acute coronary syndromes: Results from the Crusade Quality Improvement Initiative. Perform serial ECGs even if symptoms are constant.

STEMI 107

STEMI Coronary Heart Attack ACS 107

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

OCTOBER 18, 2023

6] Among 394 emergency department Code STEMI patients with acute culprit lesion requiring coronary interpretation, 16 (4.1%) presented with an ECG labeled ‘normal’ or ‘otherwise normal’ by computer interpretation. have published a number of warnings about the previous reassuring studies.[4,5]

STEMI 119

STEMI Emergency Department Coronary OR 119

Dr. Smith's ECG Blog

JULY 31, 2020

Their OMI Manifesto details how use of standard STEMI criteria results in an unacceptable level of inaccuracy, in which an estimated 25-30% of acute coronary occlusions are missed! The finding of dynamic ST-T wave changes on serial tracings in association with a change in chest pain symptoms ( SEE My Comment in the July 21, 2020 post ).

STEMI 52

STEMI Coronary EMR ALS 52

ACEP Now

APRIL 4, 2024

This patient had known coronary artery disease (CAD), and previously required drug eluting stents to the obtuse marginal and diagonal arteries. 1 Despite the rarity of dextrocardia, coronary artery disease can occur with a similar frequency to that of the general population. Coronary heart disease in situs inversus totalis.

Coronary 40

Coronary STEMI CAD Emergency Department 40

Dr. Smith's ECG Blog

JUNE 28, 2019

K EY P oints : This patient has known coronary disease. In this patient with documented coronary disease — these q waves could reflect prior lateral infarction ( especially in view of the Q in lead aVL ). I would have loved to see an ECG on this patient prior to development of coronary disease. It was stented.

Coronary 52

Coronary ACS ED OR 52

REBEL EM

JANUARY 29, 2024

What They Did: Single-center, pilot prospective observational cohort trial in Turkey Thrombolysis 25mg of alteplase without a bolus was administered over 6 hours by peripheral IV infusion If hemodynamic instability persisted despite first dose of thrombolysis, a second 6hr infusion of 25mg alteplase without bolus was administered (No patients in the (..)

ALS 136

ALS ACS OR CPR 136

ACEP Now

JUNE 6, 2023

Notoriously elusive, with a high misdiagnosis rate, thoracic aortic dissection (AD) can mimic many conditions, including acute coronary syndrome (ACS, the most common), gastroesophageal reflux disease (GERD), stroke, and spinal-cord compression. 1 Opioids or anxiolytics are often given to patients whose diagnosis of AD is missed or delayed.

ACS 85

ACS ALS ED OR 85

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. As cardiology documented, “possible STEMI. Start using the terms acute coronary occlusion and occlusion MI.

STEMI 52

STEMI Coronary OR ACS 52

Dr. Smith's ECG Blog

JULY 11, 2018

This is of course diagnostic of an acute coronary occlusion MI (OMI) that also meets STEMI criteria. The condition of the coronary artery at the time of angiogram may be different than it was 30 minutes prior during recording of the ECG. A 40-something woman had sudden chest pain. She called 911. The proposed mechanism is complex.

Coronary 52

Coronary STEMI ED ALS 52

Dr. Smith's ECG Blog

JULY 27, 2023

I was not worried for a coronary etiology. Possible explanations include: i ) Coronary vasospasm, with a brief period of coronary occlusion; ii ) Supply-demand mismatch ( Type II MI ) — precipitated by amphetamine-induced catecholamine surge; and / or , iii ) Catecholamine-mediated platelet aggregation with subsequent thrombus formation.

Coronary 52

Coronary ACS Naloxone Plasma 52

Dr. Smith's ECG Blog

DECEMBER 29, 2023

STEMI criteria is bad at differentiating between normal variant and acute coronary occlusion or reperfusion, and initial troponin levels don't differentiate between occlusive and non-occlusive MI 3. the presence of J waves from early repolarization doesn’t rule out an acute coronary occlusion 4.

STEMI 70

STEMI Coronary OR ALS 70

Dr. Smith's ECG Blog

SEPTEMBER 9, 2024

You can easily imagine this patient getting one of several diagnoses -- vasospasm, MINOCA , pericarditis, or maybe even no diagnosis at all beyond "non-obstructive coronary artery disease." Another option would be to use Optical Coherence Tomography for Coronary Imaging ). That plaque is at risk of thrombosing again.

OR 66

OR Coronary ACS EMS 66

Dr. Smith's ECG Blog

JANUARY 31, 2020

But it does prove that the patient has coronary disease and makes the probability that his chest pain is due to ACS very very high. Instantaneous wave-free ratio is performed using high fidelity pressure wires that are passed distal to the coronary stenosis. Acute T-waves are large, even if not necessarily hyperacute.

ED 52

ED Coronary ACS CAD 52

Dr. Smith's ECG Blog

MARCH 19, 2023

To realize — Assessment of ECG #1 is complicated by knowing: i ) That today’s patient has a history of documented CAD ; and , ii ) The lack o f a prior tracing for comparison at the time the initial ECG was interpreted. Figure-1: Comparison between the first 3 ECGs in today’s case. What We Learn from the Prior Tracing?

STEMI 52

STEMI Coronary CAD OR 52

Dr. Smith's ECG Blog

MARCH 27, 2025

Nurse notes: the silent scream of the heart The emergency nursing notes document the patient complaining of chest pain refractory to nitro, with a rising trop: 2200: ECG shown to ED MD 0020: repeat ECG shown to ED MD, patient complain of midsternal chest pain 0520: nitro x 3. . Not whether there was or was not Acute Coronary Occlusion.

STEMI 52

STEMI Coronary ACS OR 52

Dr. Smith's ECG Blog

APRIL 15, 2019

[link] An angiogram was done: It showed no culprit and no coronary disease, but did show a myocardial bridge in the mid LAD. An excellent review of myocardial bridging, with full text: [link] Myocardial bridging is when the coronary artery, usually the LAD, dives into the myocardium.

Coronary 40

Coronary STEMI OR ED 40

Dr. Smith's ECG Blog

MAY 16, 2023

Emergent CT coronary angio also likely has a role in such cases. Like they would for any other acute arterial occlusion syndrome (such as suspicion of acute large vessel stroke), they take the patient across the hall and perform an immediate CT (coronary) angiogram, showing patent coronaries.

Coronary 52

Coronary STEMI ED OR 52

EMDocs

JANUARY 11, 2024

Early coronary angiography in post-CA patients with no ST-segment elevation on the presenting ECG may still be of benefit by potentially salvaging myocardium and decreasing the incidence of systolic heart failure in survivors (95.7%, 22/23). Individualize RBCTs to the clinical situation (81%, 17/21).

Critical Care 97

Critical Care E-9-1-1 OR ICU 97

Dr. Smith's ECG Blog

JUNE 14, 2017

The P wave is positive in lead aVL of ECG #3, which means it is a low atrial (or probably coronary sinus) rhythm — which of itself is not necessarily “abnormal” in a child if there is no other sign of underlying heart disease. As we see in ECG #3 — the regular rhythm is NOT sinus, because the P wave is negative in lead II.

STEMI 52

STEMI Coronary ED OR 52

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

Ongoing pain noted throughout all documentation, but after nitro drip and prn morphine, "pain improved to 2/10." Association of intravenous morphine use and outcomes in acute coronary syndromes: Results from the CRUSADE Quality Improvement Initiative. Repeat ECG: New developing Q waves in V2 and V3, further confirming evolving OMI.

E-9-1-1 78

E-9-1-1 ACS STEMI Coronary 78

ACEP Now

MARCH 14, 2024

Acute myocardial infarction with normal and near normal coronary arteries. Documentation with coronary arteriography within 12 1/2 hours of the onset of symptoms in two cases (three episodes). Electrical injuries in the emergency department: an evidence-based review. Emerg Med Pract. 2018 Nov;20(11):1-20. Am J Cardiol.

Operating Room 52

Operating Room ACS Critical Care Coronary 52

Dr. Smith's ECG Blog

MARCH 31, 2023

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

JULY 3, 2018

After admission he undergoes another ECG, though it is unclear from documentation whether there was a change in his chest pain. Documentation strongly suggests that this finding was what ultimately convinced the cardiologists that this was not pericarditis. After this result he was given therapeutic enoxaparin. Teaching points: 1.

ACS 52

ACS STEMI Coronary CAD 52

Dr. Smith's ECG Blog

OCTOBER 6, 2018

The patient was in his 50s with history of hypertension, diabetes, seizure disorder, and smoking, but no known coronary artery disease. No patient should have to be "lucky" by having a positive troponin to be taken seriously as a possible acute coronary occlusion. 418 of these 1788 (23%) had acute coronary occlusion.

STEMI 40

STEMI Coronary ALS OR 40

Dr. Smith's ECG Blog

APRIL 17, 2023

His HEAR score (before troponin resulted) was documented at 3, with documentation stating "low suspicion for ACS." Chest pain is documented as ongoing. Repeat 0157 with ongoing chest pain: Basically the same features diagnostic of LAD occlusion. QOH: "OMI High confidence". Physician interpretation: "No STEMI."

OR 52

OR STEMI ACS Emergency Department 52

Dr. Smith's ECG Blog

OCTOBER 2, 2021

We assume that at some point the patient's pain returned, but it is not documented, so exactly when this happened is uncertain. Immediately after the second ECG was performed, the patient's pain resolved completely. After reviewing the case, cardiology requested that the patient be admitted to observation for stress testing the next morning.

OR 52

OR ACS STEMI Coronary 52

Dr. Smith's ECG Blog

DECEMBER 14, 2018

. == It is certainly possible that IF the timing had been such that this patient’s initial ECG was normal ( as it was for ECG #2 in Figure-1 ) — that the severity of this patient’s underlying coronary disease could have been overlooked. Chest Pain scores can be misleading.

ED 52

ED STEMI Coronary Emergency Department 52