Dr. Smith's ECG Blog

OCTOBER 1, 2023

This patient in today's case was a man in his 60s with a known history of coronary disease, including prior stents. This history immediately places this patient in a high -prevalence population for having an acute event. It's OK not to be certain from the initial ECG as to whether or not an acute event is occurring.

OR 127

OR STEMI Coronary CAD 127

Dr. Smith's ECG Blog

DECEMBER 7, 2023

I quickly reviewed the patient’s records and saw that she was a 53 year old woman with a history of BMI 40, but no other identifiable risk factors for coronary artery disease. In this patient with stuttering symptoms and rising troponin, there is no other option but to perform emergent coronary angiography. Hers is shown below.

Coronary 124

Coronary OR 124

Dr. Smith's ECG Blog

DECEMBER 19, 2023

The commonest causes of MINOCA include: atherosclerotic causes such as plaque rupture or erosion with spontaneous thrombolysis, and non-atherosclerotic causes such as coronary vasospasm (sometimes called variant angina or Prinzmetal's angina), coronary embolism or thrombosis, possibly microvascular dysfunction. This is not the case.

E-9-1-1 127

E-9-1-1 Coronary ACS BLS 127

Dr. Smith's ECG Blog

JANUARY 25, 2024

A 40-something with severe diabetes on dialysis and with known coronary disease presented with acute crushing chest pain. Smith offers the unique perspective of assessing the initial ECG of a patient who has had prior events — and, who now presents with new symptoms. Here is his ED ECG: What do you think?

Coronary 75

Coronary ED OR 75

Dr. Smith's ECG Blog

OCTOBER 15, 2024

Additionally, his cardiac telemetry monitor showed runs of accelerated idioventricular rhythm, a benign arrhythmia often associated with coronary reperfusion. Patient # 1: Assessment of the Initial ECG in the ED … The History for Patient #1 — is clearly concerning for a higher -risk likelihood of having an acute event.

OR 116

OR STEMI Coronary ED 116

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

A 56 year old male with a history of diabetes, dyslipidemia, hypertension, and coronary artery disease presented to the emergency department with sudden onset weakness, fatigue, lethargy, and confusion. This is another case sent by the undergraduate (who is applying to med school) who works as an EKG tech. No ECG was ordered on Day #1.

Coronary 120

Coronary STEMI Emergency Department OR 120

Dr. Smith's ECG Blog

APRIL 22, 2024

A comparison of electrocardiographic changes during reperfusion of acute myocardial infarction by thrombolysis or percutaneous transluminal coronary angioplasty. Total coronary occlusion, if very brief, may have minimal infarction and yet be very dangerous. Am Heart J. 2000;139:430–436.

Coronary 118

Coronary STEMI ED OR 118

Dr. Smith's ECG Blog

MAY 20, 2024

The scan also showed “scattered coronary artery plaques”. __ Smith comment 1 : the appropriate management at this point is to lower the blood pressure (lower afterload, which increases myocardial oxygen demand). They too have dense white masses consistent with coronary atherosclerosis. The blue circle shows the LCx.

CAD 126

CAD STEMI Coronary ACS 126

Dr. Smith's ECG Blog

MAY 10, 2023

A CT Coronary angiogram was ordered. Here are the results: --Minimally obstructive coronary artery disease. --LAD Although a lesion is not visible anatomically on this CT scan, coronary catheter angiography could be considered based on Cardiology evaluation." A repeat troponin returned at 0.45 CAD-RADS category 1. --No

Coronary 52

Coronary STEMI CAD OR 52

Dr. Smith's ECG Blog

APRIL 2, 2024

For this reason we did not believe this was an acute coronary event and did not activate the cath lab. Here is the troponin profile overnight: This is consistent with cardiac arrest without acute coronary occlusion. So a dual chamber pacer is placed with one lead through the coronary sinus to the LV. Cardiology agreed.

Defibrillator 133

Defibrillator Coronary Epinephrine CPR 133

Critical Care Scenarios

OCTOBER 11, 2023

Takeaway lessons * Type B dissections do not involve the heart or coronaries, but Type A vs B nomenclature is falling out of favor versus more anatomically specific labeling; this system helps characterize the gray area between the innominate and the left subclavian. * Find us on Patreon here! Buy your merch here!

Naloxone 100

Naloxone Coronary OR 100

The Skeptics' Guide to EM

APRIL 10, 2021

This has been to prevent the horrible adverse event called osmotic demyelination syndrome (ODS). There is a high mortality associated with hyponatremia [1-3]. Symptomatic hyponatremia has traditionally been treated with a careful slow continuous infusion of hypertonic saline.

Emergency Department 130

Emergency Department Coronary ED OR 130

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. But that’s not always the case.

STEMI 112

STEMI Coronary OR EMS 112

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. that is, show a pattern of labile ST-T wave changes not due to an acute coronary event. I personally can hardly wait for that future version!

E-9-1-1 116

E-9-1-1 Coronary EMS ED 116

ACEP Now

OCTOBER 29, 2024

Does that normal troponin and ECG obviate the need for cardiology consultation for my patient with a concerning story for acute coronary syndrome? Development of the Canadian Syncope Risk Score to predict serious adverse events after emergency department assessment of syncope. 2016;188(12):E289-E298.

Emergency Department 59

Emergency Department ALS Emergency Medical Services OR 59

EMS 12-Lead

AUGUST 22, 2022

Beats 9-12 : Continuation of the previously described events, all inducible by the pause (and thus, prolongation of refractoriness) created by the PVC of Beat 8. The coronary angiogram revealed no critical stenosis, or acute plaque ulceration. Beat 4 abruptly halts this repetitious cycle via Peel Back.

E-9-1-1 130

E-9-1-1 Coronary ALS ICU 130

Dr. Smith's ECG Blog

OCTOBER 3, 2024

Coronaries were clean. Negative serial Troponins were needed to rule out an acute event. If a final test was perceived as "needed" — perhaps a normal coronary CT angiogram could have helped to avoid cardiac catheterization. Sam : "Yes, this case was sent to me. It was a man in his 30s with chest pain.

E-9-1-1 124

E-9-1-1 Coronary ALS ED 124

EMDocs

SEPTEMBER 15, 2023

ST segment elevation, or even an isoelectric ST segment, in these leads is abnormal and should make us concerned for ischemia Source Acute Coronary Occlusion in a Patient With Prior Known Right Bundle Branch Block: Another Chink in the Armor for the ST-Elevation Myocardial Infarction Criteria. Ann Emerg Med. 2023 Aug;82(2):219-221.

Emergency Medical Services 85

Emergency Medical Services Coronary Emergency Department EMS 85

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 117

STEMI Coronary ACS ED 117

Dr. Smith's ECG Blog

SEPTEMBER 26, 2023

There was no association between moderate to severe chest pain on arrival and major adverse cardiac events at 6 months (20% vs. 14%, p=0.12). Chest pain severity was assessed upon admission to the primary percutaneous coronary intervention hospital. We analyzed 1409 STEMI activations (69% male, 66.3 years old ± 13.7

STEMI 119

STEMI Coronary Emergency Medical Services OR 119

Dr. Smith's ECG Blog

DECEMBER 13, 2023

Knowing the patient has a history of coronary disease could be relevant to today's case — as it should add to our suspicion of a new acute event. If this is the case — this size of a Qr wave in lead III, as well as the seemingly wide Q in lead aVF — would seem to suggest prior inferior infarction a t some point in the past.

EMR 123

EMR Coronary OR STEMI 123

EMDocs

FEBRUARY 7, 2024

GLP-1 agonists are also associated with improved ejection fraction, coronary blood flow, and cardiac output while reducing the risk of cardiovascular events, infarction size, and all-cause mortality. Adverse events are common in those using GLP-1 agonists, but the vast majority of these are minor. What are the complications?

Allergic Reaction 97

Allergic Reaction ALS CAD OR 97

Dr. Smith's ECG Blog

OCTOBER 24, 2019

The biphasic T wave is consistent with recent reperfusion of an occluded coronary artery supplying the inferior region. Here’s the angiogram of the RCA : No thrombus or plaque rupture in the RCA (or any coronary artery) was found. This MI wasn’t caused by a ruptured plaque of CAD - it was a coronary artery dissection of the RCA.

Coronary 52

Coronary CAD ACS STEMI 52

Dr. Smith's ECG Blog

SEPTEMBER 11, 2024

The initial ECG in today's case was recognized as definitely abnormal — but the question arose as to whether this ECG indicated old infarction vs a new acute event. LV Aneurysm vs New Infarction?

EMS 114

EMS CPR ED Coronary 114

Dr. Smith's ECG Blog

AUGUST 6, 2024

All coronary arteries were patent without atherosclerotic change. Dr. Myocarditis can be very difficult to separate from OMI on ECG, and often some form of coronary artery imaging will need to be done to rule out OMI. The ECG shows slight ST Elevation in an inferolateral distribution. Notice how QOH is not fooled by this ST-Elevation.

Coronary 104

Coronary OR STEMI EMS 104

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

Takotsubo is a sudden event, not one with crescendo angina. 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. An angiogram is a "lumenogram;" most plaque is EXTRALUMINAL!!

Emergency Department 52

Emergency Department E-9-1-1 Coronary STEMI 52

Dr. Smith's ECG Blog

SEPTEMBER 5, 2024

Another possible cause of pseudonormalization of T waves mentioned many times on this blog is the pseudonormalization caused by re-occlusion of an infarct related reperfused coronary artery. Not all patients with acute ( or recent ) MI have chest pain with their event. This does not fit with the clinical scenario in today's case.

STEMI 109

STEMI Coronary OR ALS 109

Dr. Smith's ECG Blog

JUNE 5, 2023

have perfect coronary flow by the time of angiogram. The fatter-than-it-should-be T wave in lead aVL is the mirror image opposite picture of the ST-T wave in lead III ==> reciprocal change that strongly suggests a recent ( if not still ongoing acute ) event. Aside on ECG Research: 20% of Definite diagnostic STEMI (Cox et al.)

STEMI 96

STEMI Coronary ED Ambulance 96

Dr. Smith's ECG Blog

SEPTEMBER 7, 2024

A comparison of electrocardiographic changes during reperfusion of acute myocardial infarction by thrombolysis or percutaneous transluminal coronary angioplasty. Impression: In a patient with new symptoms — early repolarization is a diagnosis of exclusion to be made only after you have ruled out the possibility of an acute event.

STEMI 116

STEMI ACS Critical Care Coronary 116

Dr. Smith's ECG Blog

SEPTEMBER 22, 2023

As discussed above in Dr. Smith's excellent discussion — serial ECGs, correlated to severity of patient symptoms soon confirmed the acute event in today's patient. Once I find 1 or 2 of those leads — closer scrutiny of the remaining 10 leads usually reveals enough abnormalities to support my suspicion.

OR 131

OR STEMI Coronary 131

Dr. Smith's ECG Blog

JULY 22, 2012

Blunt cardiac injury my result in : 1) Acute myocardial rupture with tamponade 2) Valve rupture (tricuspid, aortic, mitral) 3) Coronary thrombosis or dissection (and thus Acute MI) from direct coronary blunt injury 4) Dysrhythmias of all kinds. Finally, this may just be an incredibly rare event that none of us will ever see again.

Coronary 52

Coronary ICU OR ED 52

Dr. Smith's ECG Blog

NOVEMBER 5, 2023

By Magnus Nossen, edits by Grauer and Smith The patient is a 70-something female with DMII, HTN and an extensive prior history of coronary artery disease and myocardial infarctions. PLUS — Today's patient is an older woman with known severe coronary disease who presented with new chest pain. She's had multiple PCI procedures.

Coronary 111

Coronary OR ALS 111

Dr. Smith's ECG Blog

JULY 31, 2018

Subsequent events: Later, before being taken to her room, the 2nd troponin returned at 1.01 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. She felt more comfortable being admitted.

Coronary 52

Coronary ACS STEMI OR 52

Dr. Smith's ECG Blog

OCTOBER 8, 2024

KEY Point: The important distinction that has to be made in today's case, is between ECG findings consistent with this patient's prior LAD OMI — vs — ECG findings of a new acute event superimposed on these prior ECG findings. My "eye" was immediately drawn to leads V1 , V2 , V3 ( within the RED rectangle ).

OR 123

OR STEMI ICU Coronary 123

Dr. Smith's ECG Blog

SEPTEMBER 3, 2010

He subsequently had a syncopal event and was down for 1-2 minutes. The patient had a positive troponin, underwent cath which showed completely clean coronaries, and then underwent EP testing which revealed that, in atrial fibrillation, he has an R-R interval as short as 220 ms, which is dangerously short. His wife called 911.

STEMI 52

STEMI Coronary EMS ED 52

ECG & Echo Learning

OCTOBER 28, 2023

Summary Indications Prasugrel, in combination with acetylsalicylic acid (ASA), is indicated for the prevention of atherothrombotic events in adult patients with acute coronary syndromes undergoing percutaneous coronary intervention (PCI). – Active bleeding. – Previous stroke or transient ischemic attack.

Coronary 52

Coronary OR 52

Dr. Smith's ECG Blog

NOVEMBER 15, 2013

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). Prevalence of Total Coronary Occlusion during the Early Hours of Transmural Myocardial Infarction. Akkerhuis KM, et al.

Coronary 52

Coronary STEMI ALS Emergency Department 52