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. This is diagnostic of full reperfusion.] An old ECG was found: As you can see, this patient has zero baseline STE, and normal T-waves. 90% of normals have some STE in V2 and V3.

OR 130

OR STEMI Coronary 130

The Skeptics' Guide to EM

MAY 19, 2018

Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events
 Among Low-Risk Emergency Department Patients: The PROPER Randomized Clinical Trial. Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events
 Among Low-Risk Emergency Department Patients: The PROPER Randomized Clinical Trial.

Emergency Department 130

Emergency Department ALS Coronary OR 130

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

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 122

OR STEMI ICU Coronary 122

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? Coming into triage, I see a young man—Georgian-speaking—bracing himself with a hand against the wall and holding his lower abdomen.

Emergency Department 59

Emergency Department ALS Emergency Medical Services OR 59

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 125

CAD STEMI Coronary ACS 125

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 112

STEMI Coronary OR EMS 112

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

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

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

SEPTEMBER 25, 2024

Here is the post shock ECG: Cardiology was called stat for ischemic VT, query SCAD vs thrombotic occlusion vs coronary vasospasm. Cath lab was activated: There was no coronary artery disease, but there was spontaneous coronary artery dissection (SCAD) of the distal LAD, which was narrowed by 95%, and treated medically.

OR 66

OR STEMI ACS Coronary 66

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

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. What do you think?

Defibrillator 132

Defibrillator Coronary Epinephrine CPR 132

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. Pattern A evolves into Pattern B. Am Heart J. 2000;139:430–436. Am J Cardiol.

Coronary 117

Coronary STEMI ED OR 117

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. A 12 Lead ECG was recorded secondary to bizarre telemetry findings at bedside. Said differently, it’s a mess. The reason for this is Phase III block. slowing of the heart rate).

E-9-1-1 130

E-9-1-1 Coronary ALS ICU 130

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. So when she sees what appear to be reperfusion (Wellens') waves, as there are in aVL and V3, she reports "OMI". I personally can hardly wait for that future version!

E-9-1-1 116

E-9-1-1 Coronary EMS ED 116

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 89

Emergency Medical Services Coronary Emergency Department EMS 89

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

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. This was sent to me from Sam Ghali ( @EM_Resus ) with no other information. What do you think, Steve?

E-9-1-1 123

E-9-1-1 Coronary ALS ED 123

Dr. Smith's ECG Blog

JUNE 17, 2016

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. KEY POINTS from this CASE: The presenting history often provides invaluable clues to the likelihood of an acute cardiac event. (

STEMI 52

STEMI OR Coronary EMS 52

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 66

OR Coronary ACS EMS 66

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. Deutch et al.

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. 414 patients were included in the analysis. 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

Dr. Smith's ECG Blog

DECEMBER 29, 2018

In view of the clinical setting ( a 50yo man with diabetes and hypertension ) — I thought these findings more than enough to qualify for an ECG determination of L VH. == M y I nitial I mpression of E CG # 1 : I was not at all certain from this initial tracing if the findings in ECG #1 represented an acute event. The patient did well.

OR 52

OR STEMI Coronary ED 52

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. Take for example semaglutide.

Allergic Reaction 98

Allergic Reaction ALS CAD OR 98

Dr. Smith's ECG Blog

NOVEMBER 1, 2022

The 50-something patient with history of coronary stenting and slightly reduced LV ejection fraction. which would suggest reduced rates of major adverse cardiac events with coronary artery bypass grafting." On the other hand, stable EKG over an hour in the setting of ongoing acute coronary syndrome is again unusual.

Overdose 52

Overdose OR Coronary ACS 52

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. In any case, the ECG is diagnostic of severe ischemia and probably OMI. Concordant STE of 1 mm in just one lead or 2a.

Coronary 104

Coronary OR STEMI EMS 104

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

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. She's had multiple PCI procedures. On the day of presentation she complained of typical chest pain, and stated it feels like prior MI. It is shown below.

Coronary 111

Coronary OR ALS 111

EMS 12-Lead

APRIL 2, 2022

He reported a history of ischemic cardiomyopathy with coronary stent placement approximately 10 years prior, but could not recall the specific artery involved. Whether this represents a potential acute cardiac event would depend on the history, comparison with prior tracings and serial tracings. Figure 1-2. Is it LBBB, or LAFB?

ALS 130

ALS STEMI Coronary OR 130

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. There are also subtly hyperacute T-wave in I, aVL, and V2-V6. The S-wave is reconstituted. The inferior findings are much less pronounced. Lemkes et al. Am Heart J.

STEMI 115

STEMI ACS Critical Care Coronary 115

Dr. Smith's ECG Blog

FEBRUARY 1, 2023

Young people can have acute coronary occlusion. Symptoms don’t always correlate with coronary artery occlusion/reperfusion: resolved symptoms but ongoing ECG signs of occlusion requires reperfusion. Are there any signs of occlusion or reperfusion?

OR 52

OR STEMI Coronary ACS 52

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. We send each other EKG by the dozens every day.

STEMI 96

STEMI Coronary ED Ambulance 96

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