ALiEM

FEBRUARY 16, 2024

An 86-year-old man with a past medical history of coronary artery disease, hypertension, hyperlipidemia, chronic kidney disease, COPD, choledocholithiasis requiring ERCP and sphincterotomy 2 years ago presented with five days of feeling unwell. History was limited due to cognitive impairment. He denied changes to urination or bowel movements.

Coronary 161

Coronary OR 161

Dr. Smith's ECG Blog

SEPTEMBER 19, 2023

Past medical history includes coronary stenting 17 years prior. 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. Initial ED ECG: What do you think?

Coronary 139

Coronary OR EMS ED 139

Dr. Smith's ECG Blog

DECEMBER 11, 2023

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. For the same reason, you should not delay coronary angiography because pain resolves with morphine. So I would be worried about inferior OMI. A patient with OMI can have a totally normal ECG!"

E-9-1-1 123

E-9-1-1 ACS Coronary STEMI 123

EMDocs

DECEMBER 11, 2023

Emergency physicians have recognized for some time that there are many occlusions of the coronary arteries that do not present with classic STEMI criteria on the ECG. This included the addition several new STEMI equivalents [4] on ECG that warrant “prompt evaluation for emergency coronary angiography.”

STEMI 119

STEMI Coronary Emergency Department OR 119

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 135

Defibrillator Coronary STEMI CPR 135

ALiEM

OCTOBER 20, 2023

A 50-year-old Caucasian female with a history of hypertension, coronary artery disease, and insulin-dependent diabetes mellitus presents to the emergency department with a complaint of painful sores on the top of her left foot. View other cases from this Clinical Image Series on ALiEM.

Plasma 161

Plasma Coronary Emergency Department OR 161

ACEP Now

OCTOBER 29, 2024

Caring for critically ill patients with limited information requires snap assessments and judgements for timely resuscitation and efficient emergency department throughput. In the age of big data, more information sounds like a boon. With what I can only describe as a “grimace” by a singular word, his face conveyed so much more.

Emergency Department 59

Emergency Department ALS Emergency Medical Services OR 59

Dr. Smith's ECG Blog

MAY 27, 2024

1] But there are multiple other abnormalities that make this ECG diagnostic of Occlusion MI, localized likely to the right coronary artery: 1. Systematic review and meta-analysis of diagnostic test accuracy of ST-segment elevation for acute coronary occlusion. But STEMI criteria is only 43% sensitive for OMI.[1] De Alencar Neto.

STEMI 123

STEMI Coronary ALS Emergency Department 123

The Skeptics' Guide to EM

MAY 19, 2018

Listen to the podcast on iTunes to hear Dr. Kline discuss some background information on the diagnosing of pulmonary embolism and the PERC Rule. * The eight-items include the following clinical criteria. If the answer to any of these questions is positive a d-dimer is indicated.

Emergency Department 130

Emergency Department ALS Coronary OR 130

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 110

STEMI Coronary OR ED 110

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

OCTOBER 3, 2024

This was sent to me from Sam Ghali ( @EM_Resus ) with no other information. Coronaries were clean. If a final test was perceived as "needed" — perhaps a normal coronary CT angiogram could have helped to avoid cardiac catheterization. I assumed it was a patient with acute chest pain. What do you think, Steve? Real or just fake?"

E-9-1-1 124

E-9-1-1 Coronary ALS ED 124

Dr. Smith's ECG Blog

FEBRUARY 9, 2024

Posterior leads are unnecessary if anterior leads are diagnostic According to the STEMI paradigm an ECG has to have ST elevation to diagnose acute coronary occlusion, and if there’s no ST elevation on anterior leads you can look for it on posterior leads. If so, how will they change management?

STEMI 114

STEMI ACS Coronary OR 114

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. Stein et al.

E-9-1-1 139

E-9-1-1 ACS Emergency Department Coronary 139

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. Would you change you interpretation if the following information was added? B elow are 4 ECGs from the same patient. At the bottom will be five alternative clinical scenarios to explain the findings.

Coronary 111

Coronary OR ED 111

Dr. Smith's ECG Blog

JULY 21, 2024

It shows a proximal LAD occlusion, in conjunction with a subtotally occluded LMCA ( Left Main Coronary Artery ). Upon contrast injection of the LMCA, the patient deteriorated, as the LMCA was severely diseased and flow to all coronary arteries ( LAD, LCx and RCA ) was compromised. He was taken immediately to the cath lab.

Defibrillator 131

Defibrillator Coronary ALS STEMI 131

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). A Coronary angiogram from 8 years prior revealed that he had had an inferior posterior STEMI at the time due to 100% occlusion of the proximal RCA.

STEMI 115

STEMI Coronary ED Paramedic 115

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

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

OCTOBER 18, 2023

I sent the top ECG to Dr Smith with no information and without the baseline ECG. The patient was referred for coronary angiography which did not reveal any atherosclerotic changes. A formal echo at the PCI center after coronary angiography revealed a large septal and apical WMA. The chest pain quickly subsided.

Defibrillator 122

Defibrillator Advanced Life Support Coronary Life Support 122

Dr. Smith's ECG Blog

DECEMBER 12, 2022

Written by Pendell Meyers I was reading ECGs in a database (without any clinical information) when I came to this one: What do you think? For clarity in Figure-1 — I've reproduced the initial ECG that was shown above in today's case, which Dr. Meyers ventured to read without the benefit of any clinical information.

OR 52

OR ACS STEMI Coronary 52

Dr. Smith's ECG Blog

JUNE 15, 2023

Written by Pendell Meyers Both of these cases were sent to me with no information other than adults with acute chest pain. What would be your response? Case 1: Case 2: What if I told you that Case 1 has an abnormal initial troponin, and Case 2 has a normal initial troponin? Case 1 An elderly male presented with chest pain. What a farce.

STEMI 98

STEMI Coronary ACS OR 98

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. STE at 60 ms after the J-point is substantially higher than at the J-point.

STEMI 52

STEMI OR Coronary EMS 52

The Skeptics' Guide to EM

JANUARY 22, 2020

As crude measures they fail to incorporate any other information into their estimates, including potential confounders for the relationship between the test result and the outcome. Sensitivity and Specificity are crude metrics, meaning they only look at the effect of a single measure and a single outcome.

Coronary 100

Coronary OR 100

Dr. Smith's ECG Blog

DECEMBER 29, 2018

Clearly, more information is needed before a definite decision can be reached — but the “onus of proof” is on the clinician to rule out acute LAD occlusion. There is a small amount of STE in V2 and V3, with a very small amount of STD in V4-V6. The T-waves are not definitively hyperacute. There was no prior for comparison.

OR 52

OR STEMI Coronary ED 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. Of the Non-STEMI in our cohort, about 25% will actually have acute coronary occlusion. EMS arrived and recorded this ECG: What do you think?

STEMI 98

STEMI Coronary Paramedic OR 98

EMDocs

SEPTEMBER 26, 2024

Patient not informed of enlarged heart, dies 3 weeks post ED visit Miscommunicated radiology findings are a hot topic. Autopsy shows coronary atherosclerosis and marked cardiomegaly with a thickened left ventricular wall. If you have a story to share click here. Who is responsible for notifying patients of post discharge findings?

Emergency Department 97

Emergency Department ED Coronary ALS 97

Dr. Smith's ECG Blog

AUGUST 9, 2024

Learning points: Both patients and other medical providers can report confusing and often contradictory information that obfuscates the diagnosis (in this case, WPW). Serial ECGs enhance the diagnosis of acute coronary syndrome. This can occur due to scar ( e.g. post infarct VT) or anatomical variants ( e.g. AVNRT or AVRT). Washam, J.

STEMI 107

STEMI Coronary Heart Attack ACS 107

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

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. Do you need to get more information? She's had multiple PCI procedures. The question is, does she need to go urgently to the cath lab or can she wait.

Coronary 111

Coronary OR ALS 111

Dr. Smith's ECG Blog

MARCH 13, 2024

Distilling this case into its most salient components, a man with multiple risk factors for coronary disease is presenting with several days of chest pain and markedly elevated troponin with no other reason to explain the lab abnormality ( e.g. sepsis). High sensitivity troponin I (hsTnI) obtained around that time was 5548 ng/L (ref. <

Coronary 108

Coronary ACS Emergency Management Emergency Manager 108

REBEL EM

MARCH 30, 2023

Clinical Question : In patients who suffer an OHCA without ST-segment elevation on the post-resuscitation ECG, will early coronary angiogram (CAG) vs. delayed CAG improve outcomes? Emergency vs Delayed Coronary Angiogram in Survivors of Out-of-Hospital Cardiac Arrest: Results of the Randomized, Multicentric EMERGE Trial.

Coronary 66

Coronary CPR OR ICU 66

Dr. Smith's ECG Blog

DECEMBER 13, 2023

Today's CASE: We have only been provided with limited information about the patient in today's case — namely, that is a middle-aged adult who presented with CP ( C hest P ain ). 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.

EMR 123

EMR Coronary OR STEMI 123

Dr. Smith's ECG Blog

JUNE 5, 2023

Any ST Depression Maximal in V1-V4 is OMI until proven otherwise I sent this ECG with no information to Pendell. have perfect coronary flow by the time of angiogram. The large upright T-wave in V2 is consistent with reperfusion. We send each other EKG by the dozens every day. Most are OMI look alikes (mimics).

STEMI 96

STEMI Coronary Ambulance ED 96

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! Learning Point: 1.

E-9-1-1 116

E-9-1-1 Coronary EMS ED 116

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

FEBRUARY 1, 2023

Just so you know this ECG interpretation is not done by the retrospectoscope: I sent it to Dr. Smith without any information, and he immediately responded: "Infero-postero-lateral OMI" The ECG had a computer and final cardiology interpretation of “possible inferior infarct, age undetermined”, because of Q waves.

OR 52

OR STEMI Coronary ACS 52