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-9-1-1 121

E-9-1-1 ACS Coronary STEMI 121

Dr. Smith's ECG Blog

SEPTEMBER 19, 2023

Past medical history includes coronary stenting 17 years prior. Initial ED ECG: What do you think? This was shown to me with no clinical information and I said "It is VT until proven otherwise." Cardiology was consulted and the patient underwent coronary angiogram which showed diffuse severe three-vessel disease.

Coronary 136

Coronary OR EMS ED 136

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

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. I sent it to 5 of my OMI friends without any clinical information or outcome and all 5 independently responded with exactly the same diagnosis: "reperfused inferior OMI".

Defibrillator 131

Defibrillator Coronary STEMI CPR 131

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

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

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 OR 107

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

The Skeptics' Guide to EM

OCTOBER 22, 2017

Studies have shown that oxygen can cause vasoconstriction, increase blood pressure and decrease coronary artery blood flow ( Kones et al AM J Med 2011). They felt this would help inform guideline writers on making recommendations in this area. Class IIb, LOE C-LD)

Emergency Medical Services 130

Emergency Medical Services Coronary ALS STEMI 130

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

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 73

STEMI Paramedic Coronary ED 73

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 79

STEMI Coronary Ambulance ED 79

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 104

Coronary OR ED 104

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 71

Coronary STEMI EMS OR 71

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-9-1-1 137

E-9-1-1 ACS Emergency Department Coronary 137

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

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

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 90

STEMI Coronary Paramedic OR 90

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 60

STEMI Coronary CAD ED 60

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

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

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 73

E-9-1-1 Emergency Department ALS ED 73

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

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 70

STEMI Coronary OR ALS 70

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 71

Coronary OR STEMI ED 71

Dr. Smith's ECG Blog

OCTOBER 30, 2024

He arrived in our ED with the below ECG pain free. However, there was no thrombotic component and there was TIMI III flow in all coronaries and their main branches. And, even if there was acute aortic dissection — the dissection could result in occlusion of a coronary artery. There is now reperfusion of the artery.

Coronary 89

Coronary EMS OR STEMI 89

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

FEBRUARY 13, 2023

I sent the first ECG to Dr. Meyers without any information, and he replied, “good one. If the patient only had these two ECGs recorded, it would have missed the transient time between them which were STEMI positive, and the patient would then have arrived at the ED as “serial ECGs STEMI negative." Will be missed easily.” Meyers et al.

STEMI 52

STEMI Paramedic Coronary ALS 52

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

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 74

ED Coronary Ambulance OR 74

Dr. Smith's ECG Blog

OCTOBER 2, 2021

Submitted by Benjamin Garbus, MD with edits by Bracey, Meyers, and Smith A man in his early 30s presented to the ED with chest pain described as an “explosion" of left chest pressure. At the time of arrival to the ED, the patient reported 1/10 chest pain with normal vital signs. Triage EKG: What do you think? Do NOT use them.

OR 52

OR ACS STEMI Coronary 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. Admittedly — we often are not privileged to see this information.

STEMI 119

STEMI ED OR Coronary 119

Dr. Smith's ECG Blog

JUNE 11, 2021

The patient was brought to the ED as a possible Code STEMI and was seen directly by cardiology. Below is the first ED ECG, labeled LBBB by the machine. In this case, cardiology noted “old LBBB, negative Sgarbossa”, so they kept the patient in the ED for repeat ECGs and troponin levels. Vitals were HR 58 BP 167/70 R20 sat 96%.

EMR 52

EMR STEMI CPR ED 52

Dr. Smith's ECG Blog

APRIL 22, 2022

Identifying patients with low risk for acute coronary syndrome without troponin testing: validation of the HEAR score. High-sensitivity cardiac troponin I at presentation in patients with suspected acute coronary syndrome: a cohort study. Moumneh T, Sun BC, Baecker A, et al. Am J Med 2021 5. Shah ASV, Anand A, Sandoval Y, et al.

E-9-1-1 52

E-9-1-1 STEMI ALS ED 52

Dr. Smith's ECG Blog

FEBRUARY 4, 2023

Pretest probability: Especially when there is no Chest pain, or there are very atypical symptoms, one should be very suspicious of the diagnosis of coronary occlusion unless the ECG is crystal clear. STE at 60 ms after the J-point is substantially higher than at the J-point.

STEMI 52

STEMI Coronary EMS ED 52