Dr. Smith's ECG Blog

DECEMBER 11, 2023

The neighbor recorded a systolic blood pressure again above 200 mm Hg and advised her to come to the ED to address her symptoms. What would you do at this time with this information? But pain is an important signal in MI and informs the clinician of the urgency. She contacted her neighbor, a nurse, for help. At midnight.

E-9-1-1 123

E-9-1-1 Coronary ACS STEMI 123

Dr. Smith's ECG Blog

MAY 10, 2023

At this point, with the information above, the patient's overall clinical picture could be consistent with either reperfused OMI, or Non-OMI, since both may have absent pain and inverted T waves. A CT Coronary angiogram was ordered. Here are the results: --Minimally obstructive coronary artery disease. --LAD

Coronary 52

Coronary STEMI CAD OR 52

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 102

STEMI Coronary ACS ED 102

Dr. Smith's ECG Blog

OCTOBER 3, 2024

This was sent to me from Sam Ghali ( @EM_Resus ) with no other information. Coronaries were clean. ECG Features suggesting "Fake" As per Dr. Sam Ghali ( who sent us today's case ) — serial Troponins were clearly indicated since the patient presented to the ED. I assumed it was a patient with acute chest pain. Real or just fake?"

E-9-1-1 111

E-9-1-1 Coronary ALS ED 111

Dr. Smith's ECG Blog

JUNE 17, 2024

If this EKG were handed to you to screen from triage without any clinical information, what would you think? Electrocardiographic Differentiation Between Acute Pulmonary Embolism and Acute Coronary Syndromes on the Basis of Negative T Waves - ScienceDirect. What do you think? In fact, Kosuge et al. Accessed May 28, 2024.

E-9-1-1 138

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

Dr. Smith's ECG Blog

DECEMBER 9, 2023

I read this blinded, with no clinical information, and read it as inferior OMI. The Queen of Hearts interprets it blinded also (no clinical information and no previous ECGs or serial ECGs). On arrival in the ED, the patient denied any symptoms at all. They recorded a prehospital ECG: What do you think? Learning Points: 1.

STEMI 107

STEMI Coronary ED Paramedic 107

Dr. Smith's ECG Blog

NOVEMBER 27, 2023

But do they represent acute coronary occlusion? But coronaries were normal, and serial high sensitivity troponin was undetectable. Based on ECG changes and echo findings, the patient was diagnosed as coronary vasospasm. I sent both ECGs to Dr. Smith, with the only information that these were prior vs new ECG.

STEMI 89

STEMI Coronary OR ED 89

EMDocs

SEPTEMBER 26, 2024

Here’s another case from Medical Malpractice Insights – Learning from Lawsuits , a monthly email newsletter for ED physicians. Patient not informed of enlarged heart, dies 3 weeks post ED visit Miscommunicated radiology findings are a hot topic. To opt in to the free subscriber list, click here.

Emergency Department 75

Emergency Department ED Coronary ALS 75

Dr. Smith's ECG Blog

OCTOBER 12, 2023

Accompanying the ECGs is some clinical information. Look at the ECGs and consider the timeline and other information. As part of her work up in the ED an ECG was recorded. Would you change you interpretation if the following information was added? B elow are 4 ECGs from the same patient. What do you think?

Coronary 103

Coronary OR ED 103

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.

E-9-1-1 107

E-9-1-1 Coronary EMS ED 107

Dr. Smith's ECG Blog

MAY 23, 2023

The chest pain started about 24 hours ago, but there was no detailed information available about whether his pain had come and gone, or what prompted him to be evaluated 24 hours after onset. But the paramedic and the ED physician in this case did not subscribe to this idea. EMS arrived and recorded this ECG: What do you think?

STEMI 86

STEMI Coronary Paramedic OR 86

Dr. Smith's ECG Blog

JANUARY 8, 2024

I was reviewing ECGs for a study, and came across this one, and was able to get all the clinical information: What do you think? She went to angio and had normal coronaries. No d-dimer or CT pulmonary angiogram was done when they discovered that she had normal coronary arteries. I discussed all results with patient.

Coronary 75

Coronary STEMI EMS OR 75

Dr. Smith's ECG Blog

JUNE 5, 2023

Here is his initial ED ECG: What do you think? Any ST Depression Maximal in V1-V4 is OMI until proven otherwise I sent this ECG with no information to Pendell. 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.

STEMI 75

STEMI Coronary ED Ambulance 75

Dr. Smith's ECG Blog

NOVEMBER 23, 2022

Here is his triage ECG: PM Cardio version: With no other information at all, I sent this ECG to Dr. Smith, who replied: "I think it is real. About an hour later, he was then found on the floor in cardiac arrest in the ED. QUESTIONS: About 1 hour after ECG #1 was done — the patient was found on the floor in the ED in cardiac arrest.

Coronary 52

Coronary Heart Attack ED CPR 52

Dr. Smith's ECG Blog

JANUARY 9, 2023

This was sent to me with no information and I immediately replied that it was diagnostic of LAD OMI. I sent this ECG to Dr. Smith, with the only information that it is a 17 year old with chest pain. Repeat CT angio chest (not CT coronary, unclear what protocol) showed possible LAD aneurysm and thrombus.

Coronary 52

Coronary STEMI Heart Attack OR 52

Dr. Smith's ECG Blog

MAY 16, 2023

Dr. Singer sent this to me with just the information: "~40 year old with acute chest pain". Other outcome information is not available. Sadly, I did not receive enough information to adjudicate whether this patient has pericarditis or not. Emergent CT coronary angio also likely has a role in such cases.

Coronary 52

Coronary STEMI ED OR 52

EM Literature of Note

OCTOBER 18, 2021

Pervasive use of CT coronary angiography has been an unnecessary feature of the evaluation of patient with low-risk chest pain for the better part of a decade now. Patients were eligible by symptoms of an acute coronary syndrome, supported by ECG changes, an elevated troponin, or a history of ischemic heart disease.

Coronary 40

Coronary CAD ED OR 40

Dr. Smith's ECG Blog

OCTOBER 17, 2024

Written by Jesse McLaren Two patients in their 70s presented to the ED with chest pain and RBBB. The prehospital and ED computer interpretation was inferior STEMI: There’s normal sinus rhythm, first degree AV block and RBBB, normal axis and normal voltages. Coronaries were normal, as was serial troponin. Vitals were normal.

STEMI 77

STEMI Paramedic Coronary ED 77

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. Admittedly — we often are not privileged to see this information.

STEMI 119

STEMI ED OR Coronary 119

Dr. Smith's ECG Blog

JULY 16, 2022

This middle aged male with h/o GERD but also h/o stents presented to the ED with chest pain. Apparently, the patient was not satisfied, and came to the ED as he still had pain. It was extremely busy in the ED and things did not get done quickly. He had been at a clinic that day where he had complained of worsening GERD.

Coronary 52

Coronary ED EMS Critical Care 52

Dr. Smith's ECG Blog

JUNE 11, 2011

The patient arrived in the ED and had this ECG: No difference. All coronaries were completely normal. Only 5-13% of patients with chest pain and LBBB have MI; many fewer have coronary occlusion. Additionally, appropriate discordance is common in NonSTEMI, but very unusual in coronary occlusion (STEMI).

STEMI 52

STEMI Coronary ALS ED 52

EMDocs

OCTOBER 30, 2023

” – Musings of an American ED resident in July 2022 when US healthcare was affected simultaneously by supply chain issues from GE Healthcare (contrast media) and Abbott Laboratories (Similac baby formula). 3 A study of CT use trends in the ED has shown increasing use of CTs by almost 60% from 2005 to 2013.

E-9-1-1 74

E-9-1-1 Emergency Department ALS ED 74

Dr. Smith's ECG Blog

JULY 31, 2018

I saw this before any other information and knew immediately that it represented an LAD occlusion. Next day, t he patient was taken for an angiogram and found to have a reperfused LAD lesion with good flow that appeared to the angiographer as if it was a spontaneous coronary artery dissection. There is 1 mm of STE in lead V2.

Coronary 52

Coronary ACS STEMI OR 52

Dr. Smith's ECG Blog

JUNE 19, 2024

Case An 82 year old man with a history of hypertension presented to the ED with chest pain at 1211. The ED provider ordered a coronary CT scan to assess the patient for CAD. His pain suddenly became much worse in the ED and he became acutely diaphoretic, dizzy, and hypotensive. There is pericardial tamponade.

STEMI 63

STEMI Coronary CAD ED 63

Dr. Smith's ECG Blog

MARCH 17, 2023

She had a prior history of "NSTEMI" one month ago, during which she had a coronary angiogram reportedly showing no stenosis in any coronary artery. I sent the first ECG with no information at all, and without the old ECG, to Steve Smith who immediately just texted back: "pulse tapping." Her vitals were within normal limits.

Coronary 52

Coronary Emergency Department ED OR 52

Dr. Smith's ECG Blog

AUGUST 30, 2023

The ECG was sent to me with no information, and I replied "OMI". Mark Hellerman's OMI Pocket Guide ) — will immediately recognize the other critical piece of information in the history from today's patient = The patient's CP improved — and then returned , at which time she presented to the ED. No prior ECG was available.

Coronary 75

Coronary OR STEMI ED 75

Dr. Smith's ECG Blog

SEPTEMBER 14, 2014

He has had previous angiograms showing "large vessels" and "no significant coronary disease." Here is his ED ECG There is RV Pacing. Use all the information at your disposal to assess the situation. He presented with chest pain, not relieved by nitro, pain reproducible on exam and centered around the pacemaker insertion site.

STEMI 52

STEMI Coronary ED OR 52

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

Smith: If this is ACS (a big if), t his is just the time when one should NOT use "upstream" dual anti-platelet therapy ("upstream" means in the ED before angiography). Diffuse ST depression with ST elevation in aVR: Is this pattern specific for global ischemia due to left main coronary artery disease? J Electrocardiol 2013;46:240-8 2.

Coronary 52

Coronary ACS STEMI ALS 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. link] References 1.

STEMI 74

STEMI Coronary OR ALS 74

Dr. Smith's ECG Blog

NOVEMBER 17, 2014

This case was recently posted by Tyron Maartens on Facebook EKG club (he agreed to let me post it here), with the following clinical information: "42 year old male with two weeks of intermittent chest discomfort, awoke 4 hours prior to this ECG with a more severe, heavy chest pain (5/10). BP 112/80, SpO2 100%. PCI is not an option."

STEMI 52

STEMI Coronary OR ED 52

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

Don't Forget the Bubbles

OCTOBER 7, 2024

However, vertical flow can result in myocardial injury secondary to coronary artery spasm. In: Walls RM, ed. What is the source of electricity (and is there ongoing risk to others)? Was the voltage high or low (as below)? Where were the contact points and the length of the contact? Electrical Injuries. Chen P, Bukhman AK. Culnan, D.M.,

ACS 80

ACS Life Support OR CPR 80

Dr. Smith's ECG Blog

JUNE 18, 2013

I want all to know that, with the right mind preparation, and the use of the early repol/LAD occlusion formula, extremely subtle coronary occlusion can be detected prospectively, with no other information than the ECG. This was my thought: if this patient presented to the ED with chest pain, then this is an LAD occlusion.

STEMI 52

STEMI Coronary ALS CAD 52

Dr. Smith's ECG Blog

JULY 31, 2013

hours prior to ED arrival. 95 minutes later, the patient arrived in the ED and here is the triage ECG: There is 2-2.5 A coronary aneurysm was found. Some of these MIs in young people are due to anomolies: aneurysm from a disorder known to be associated with coronary aneurysms (left out to maintain anonymity) in this case.

STEMI 52

STEMI Coronary ED OR 52

Dr. Smith's ECG Blog

JULY 12, 2023

Turns out that it was a 50-something patient with no previous cardiac history who had called 911 for chest pain and had presented 75 minutes earlier by ambulance to triage (as the entire ED was overloaded). All triage ECGs are immediately shown to triage ED faculty.

ED 70

ED Coronary Ambulance OR 70

Dr. Smith's ECG Blog

APRIL 8, 2022

The ECG is diagnostic for acute transmural infarction of the anterior and lateral walls, with LAD OMI being the most likely cause (which has various potential etiologies for the actual cause of the acute coronary artery occlusion, the most common of which is of course type 1 ACS, plaque rupture with thrombotic occlusion). Aspirin 81 mg daily.

STEMI 52

STEMI Coronary ACS ED 52

Dr. Smith's ECG Blog

OCTOBER 3, 2017

Here is his ECG on presentation to the ED, approximately 45 minutes after onset of pain, but with pain improving since onset: What is your interpretation? I sent this ECG with no clinical information to Dr. Smith. The assay at my institution, for example, is frequently negative until 4-6 hours after acute coronary occlusion.

CPR 52

CPR Defibrillator STEMI ED 52