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High sensitivity cardiac troponins for ED chest pain evaluation (2022 ACC pathway)

ALiEM

The 2022 American College of Cardiology (ACC) pathway provides timely guidance [1]. Intermediate-risk patients may be further stratified based on recent stress testing or coronary angiogram findings plus a modified HEART or Emergency Department Assessment of Chest Pain (EDACS) score. Time to know your hs-cTn better.

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Acute artery occlusion -- which one?

Dr. Smith's ECG Blog

Thanks in part to rapid bedside diagnosis, the patient was able to avoid emergent coronary angiography. Here is lead I from ECGs 1 and 2 shown side-by-side to highlight the change in axis from borderline right to completely normal. While not completely ruling out acute coronary disease — another cause should be considered.

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A 30-something with acute chest pain

Dr. Smith's ECG Blog

Coronaries were clean. I agree, however: 1) I don't think you can get a good enough ech o without bubble contrast. 3) E cho is another step that takes time. I agree, however: 1) I don't think you can get a good enough ech o without bubble contrast. 3) E cho is another step that takes time. Time is myocardium.

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Of Twists and Turns

EMS 12-Lead

Initial vital signs include: NIBP 99/58 HR 150-160 (trend) RR 10 (spontaneous, but shallow) SpO2 86 (RA) BBS CTA The initial rhythm strip is attached: Figure 1 There is a wide complex tachycardia of varying morphology, amplitude, and R-R cycle length. A prominent vertical scar, however, is noted at the sternum.

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What Lies Beneath

EMS 12-Lead

Question 1: What is the rhythm? Beat 1 : Sinus, narrow QRS complex. The assumption is that a premature complex discharged prior to Beat 1, which prolonged its respective refractory period in the same manner as Beat 5. The coronary angiogram revealed no critical stenosis, or acute plaque ulceration.

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How important are old ECGs in Non-obvious cases of potential OMI?

Dr. Smith's ECG Blog

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. Learning Point: 1. For examples of such exceptions — See My Comment in the January 9, 2019 — August 22, 2020 — and June 30, 2023 posts in Dr. Smith's ECG Blog ).

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EM@3AM: Retroperitoneal Hematoma

EMDocs

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. 1 Risk Factors: 1-4 Spontaneous Anticoagulants (Apixaban, Rivaroxaban, etc.)

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