Dr. Smith's ECG Blog

NOVEMBER 25, 2024

The guide is a living document, which I (Willy Frick) will continuously update as I encounter additional angiographic images worth learning from. What follows is an introduction to angiography -- a guide meant for people with no prior experience interpreting angiograms.

Coronary 102

Coronary OR 102

Dr. Smith's ECG Blog

JUNE 7, 2024

The most likely would be #2) initially normal, then #3) subtle OMI, then #4) obvious STEMI, and then #1) reperfusion: In other words, the patient with an initially normal ECG develops an acute coronary occlusion, with ECGs that progress from subtle to obvious, and then reperfuse after angiography. 2 Normal ECG #3.

STEMI 96

STEMI Coronary OR EMS 96

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. Stein et al.

E-9-1-1 138

E-9-1-1 ACS Emergency Department Coronary 138

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 70

OR Coronary ACS EMS 70

EMDocs

SEPTEMBER 26, 2024

An unknown EP reviews the report, determines that there is no reason to notify the patient, and documents nothing. Autopsy shows coronary atherosclerosis and marked cardiomegaly with a thickened left ventricular wall. It wasn’t, so you weren’t called, nor did the doc need to document anything.

Emergency Department 75

Emergency Department ED Coronary ALS 75

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." Written by Willy Frick A 46 year old man with a history of type 2 diabetes mellitus presented to urgent care with complaint of "chest burning." The following ECG was obtained. ECG 1 What do you think?

ACS 107

ACS ALS OR STEMI 107

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.” (!!!) or basilar ischemia.

STEMI 98

STEMI Coronary Emergency Department OR 98

REBEL EM

JANUARY 29, 2024

in the paper but 2.7% to ≈0.99 (p<0.001) Mean MPI/Tei Index≈ 0.47 in the paper but 2.7% to ≈0.99 (p<0.001) Mean MPI/Tei Index≈ 0.47 in the paper but 2.7% to ≈0.99 (p<0.001) Mean MPI/Tei Index≈ 0.47

ALS 136

ALS ACS OR CPR 136

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 113

Defibrillator Coronary ALS STEMI 113

EMDocs

SEPTEMBER 19, 2023

This document covers high sensitivity troponin, risk disposition pathways, and STEMI equivalents. STEMI vs. NSTEMI dichotomy is not sensitive for true occlusion MI or acute coronary occlusion. NCSE is likely more common than we think.

STEMI 73

STEMI Coronary Emergency Department ICU 73

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. Written by Jesse McLaren Four patients presented with chest pain. minutes).

STEMI 120

STEMI Emergency Department Coronary OR 120

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 ). However , this patient is having chest discomfort, and by definition then she should be considered not to be stable. Is this: 1. In either case, prompt cardioversion is indicated.

Coronary 99

Coronary ACS ED OR 99

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

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

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

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 74

STEMI Coronary OR ALS 74

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 more leads in a given lead area that show hyperacute changes — the greater the concern for acute OMI.

STEMI 52

STEMI Coronary EMR ALS 52

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

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 86

STEMI Coronary Heart Attack ACS 86

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

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

APRIL 4, 2023

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. Q wave, old infarct?

STEMI 52

STEMI Coronary OR ACS 52

EMDocs

JANUARY 11, 2024

Brain Oxygenation, Perfusion, Edema, and ICP Statements Takeaway: Avoid 100% oxygen saturation. Instead, target 92-98%. Keep hemoglobin > 7 g/dL. Consider lowering ICP if elevated (head of bed elevation, hyperosmolar therapy, etc.). Valproic acid and levetiracetam are reasonable first-line therapies for EEG or clinical seizure activity.

Critical Care 76

Critical Care E-9-1-1 OR ICU 76

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 82

E-9-1-1 ACS STEMI Coronary 82

Dr. Smith's ECG Blog

JUNE 28, 2019

For coronary anatomy, see here: [link] This is the post intervention ECG: All ST Elevation is gone (more proof that it was all a result of ischemia) Formal Echo: Normal estimated left ventricular ejection fraction - 55%. K EY P oints : This patient has known coronary disease. It was stented. But 1% may be/have neither!

Coronary 52

Coronary ACS ED OR 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

ACEP Now

MARCH 14, 2024

Thick, dry, and calloused skin of a construction worker can have as much as 100 times more resistance than the previous example. 4 This may lead to more heat dissipated at the skin with impressive burns to skin, but less transmission of electricity to deeper tissues. High voltage” is defined by texts as 600 V and 1,000 V. Click to enlarge.)

Operating Room 52

Operating Room ACS Critical Care Coronary 52

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. I immediately responded: "cool fake!

Coronary 52

Coronary STEMI ED OR 52

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. We need to do some more investigation.

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. The interventionalist asked for another troponin, which shortly returned at 66 ng/L. What We Learn from the Prior Tracing?

STEMI 52

STEMI Coronary CAD OR 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

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

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

APRIL 15, 2020

An elderly woman with history of coronary disease presented with CP and SOB and hypotension by EMS. Angiogram: Severe coronary artery calcification Moderate to severe distal small vessel disease mainly seen in RPL1, 2 Otherwise, Mild plaque, no angiographically significant obstructive coronary artery disease.

Coronary 52

Coronary ED OR Overdose 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. But beware when it makes these calls.

STEMI 52

STEMI Coronary OR ED 52

Dr. Smith's ECG Blog

JULY 22, 2023

The patient proceeded to cath where all coronaries were described as normal with no evidence of any CAD, spasm, or any other abnormality. Our patient had a Brugada Type 1 pattern elicited by an elevated core temperature, which is also a documented phenomenon. He denied chest pain or shortness of breath. PM Cardio digitized version.

E-9-1-1 67

E-9-1-1 CAD OR STEMI 67

Dr. Smith's ECG Blog

DECEMBER 14, 2018

Even if troponins are negative and infarction is not documented — dynamic ECG changes in association with new chest discomfort is indication for investigation. He had a history of hypertension but stopped taking his medication several years ago. The patient is pretty sure that this discomfort was his reflux. BP was 200/100. What do you think?

ED 52

ED STEMI Coronary Emergency Department 52