Dr. Smith's ECG Blog

MAY 20, 2019

See this case in which the ECG which was recorded after stabilization is diagnostic: ST depression, pulmonary edema, and severe hypertension: is this demand ischemia or acute coronary syndrome? Co-culprit is a 85% bifurcating lesion of the large LADD1 related to above LAD lesion This is an important article by Widimsky et al.

ACS

Dr. Smith's ECG Blog

DECEMBER 20, 2024

Written by Willy Frick with edits by Ken Grauer An older man with a history of non-ischemic HFrEF s/p CRT and mild coronary artery disease presented with chest pain. The most common way is by delivering a lead into the coronary sinus ostium in the RA, which wraps around the posterolateral portion of the LV. Kaye et al.

Defibrillator

Dr. Smith's ECG Blog

OCTOBER 7, 2022

The T wave changes that have occurred are widespread, and not in a typical coronary distribution. Rallidis Et al. Each time the patient underwent cardiac catheterization — and each time, she had patent coronary arteries! Note also the loss of R wave amplitude in ECG #2 compared to ECG #1. This patient never had ACS.

ACS

Dr. Smith's ECG Blog

JUNE 10, 2025

Transient STEMI was studied by Lemkes et al. Lemkes JS, Janssens GN, van der Hoeven NW, et al. Available from: [link] Lemkes et al. Coronary angiography before and after intervention is shown below. This is really a transient OMI (or transient STEMI if one uses that terminology and it has diagnostic ST Elevation).

STEMI

Dr. Smith's ECG Blog

JULY 23, 2015

Without seeing the patient, my interpretation of the first ECG was: likely normal variant ST-elevation (early repolarization), with a small possibility of pericarditis, and almost no possibility of acute coronary occlusion (STEMI).

STEMI

Dr. Smith's ECG Blog

DECEMBER 16, 2024

Cardiology wanted a CT of the aorta to rule out dissection, presumably partly due to the very high blood pressure readings, but also because it is hard for people to believe that a 20-something woman could have acute thrombotic coronary artery. Coronary malperfusion due to type A aortic dissection: mechanism and surgical management.

STEMI

ACEP Now

AUGUST 4, 2025

Note This article was published in Annals of Emergency Medicine , 82, Triska J, George J, Rector G, et al., 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, 219-221, © 2023 by the American College of Emergency Physicians.”

Coronary

Dr. Smith's ECG Blog

MAY 28, 2025

Autolysis and reperfusion the right coronary artery prior to ED presentation was likely responsible for the subtle biphasic terminal T wave inversion seen on his presenting ECG. 12 hours after presentation the right coronary artery likely RE-occluded, manifesting in the clear ST segment elevation myocardial infarction seen at 2:00 AM.

Coronary

Dr. Smith's ECG Blog

APRIL 4, 2011

65 y old male, hypt, IHD, smoker, central chest pain, was in pulm oedema Killip III Great recent article relevant to this: Kosuge M, Ebina T, Hibi K, et al. An early and simple predictor of severe left main and/or three-vessel disease in patients with non-ST-segment elevation acute coronary syndrome. Am J Cardiol;107(4):495-500.

CAD

ACEP Now

MAY 9, 2025

vs 5.1%; RR Feldman E, et al; 2019. vs 5.1%; RR Feldman E, et al; 2019. vs 40.6%; p Desborough M, et al; 2017. vs 40.6%; p Desborough M, et al; 2017. 0.84) Barletta J, et al; 2016. 0.84) Barletta J, et al; 2016. Kapapa T, et al; 2014. Kapapa T, et al; 2014. units; 95% CI 1.16

Allergic Reaction

EMOttawa

JULY 14, 2025

5 Miller J, et al. Findings: The accelerated protocol did not significantly increase safe discharges (57.8% […] The post Rapid Acute Coronary Syndrome Evaluation Over One Hour With High-Sensitivity Cardiac Troponin I: A United States-Based Stepped-Wedge, Randomized Trial appeared first on EMOttawa Blog. Ann Emerg Med.

Coronary

Dr. Smith's ECG Blog

MARCH 24, 2019

The cath lab was activated and the coronaries were normal. Peguero JG et al. Procedure: Coronary angiography. Left heart catheterizatio (the AL-1 catheter entered the left ventricle during attempts at engaging the anomalous RCA). RCA: anomalous take-off probably from the left coronary cusp. Findings: 1.

Coronary

ACEP Now

JULY 2, 2025

An 86-year-old man with a history of hypertension, hyperlipidemia, cardiomyopathy, and our-vessel coronary artery bypass five years prior presented to the emergency department (ED) with one hour of sudden-onset retrosternal, pressure-like chest pain radiating to the left arm. The ECG obtained in the ED is shown above.

Coronary

The Skeptics' Guide to EM

NOVEMBER 25, 2023

Date: November 22, 2023 Reference: Stopyra et al. Date: November 22, 2023 Reference: Stopyra et al. A 12-lead electrocardiogram (ECG) demonstrates ST elevations in leads II, III, and aVF with ST depressions in leads I and aVL and the team begins transport to the nearest percutaneous coronary intervention (PCI) capable hospital.

Heart Attack

ACEP Now

DECEMBER 6, 2024

A 45-year-old male with a history of chronic obstructive pulmonary disease (COPD), asthma, amphetamine and tetrahydrocannabinol (THC) use, and coronary vasospasm presented to triage with chest pain. During assessment, the patient reported that a left heart catheterization six months prior indicated spasms but no coronary artery disease.

Coronary

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

Studies such as those by Moise et al 14 and Ellis et al 39 have shown that the relative risk of developing an acute myocardial infarction in the territory supplied by an artery with a 70%. years, with the interval as long as 12 or 18 years in some studies. Unfortunately, vascular remodeling is variable and inconsistent.

Coronary

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

Angiogram No obstructive epicardial coronary artery disease Cannot exclude non-ACS causes of troponin elevation including coronary vasospasm, stress cardiomyopathy, microvascular disease, etc. CORONARY ARTERIES: Exam was not directly tailored for coronary artery evaluation, noting recent diagnostic coronary angiogram.

Coronary

The Skeptics' Guide to EM

JULY 2, 2022

Date: June 30th, 2022 Reference: McGinnis et al. Major adverse cardiac event rates in moderate-risk patients: Does prior coronary disease matter? Date: June 30th, 2022 Reference: McGinnis et al. Major adverse cardiac event rates in moderate-risk patients: Does prior coronary disease matter? Reference: McGinnis et al.

Coronary

Dr. Smith's ECG Blog

JUNE 5, 2024

Why Was Cardiac Cath Negative for Coronary Disease? As noted by Dr. Nossen — this patient qualified as MINOCA ( M yocardial I nfarction with N on- O bstructive C oronary A rteries ) — since troponin was positive on his 2nd admission, yet there was no evidence of obstructive coronary disease on cath.

Coronary

EMOttawa

APRIL 9, 2024

Methodology: 3/5 Usefulness: 2/5 Ashburn NP, et al. Question and Methods: The authors completed preplanned subgroup analyses to determine if a 0-1 hour ultra-sensitive troponin […] The post Sensitivity Cardiac Troponin T Among Patients With Known Coronary Artery Disease appeared first on EMOttawa Blog. JAMA Cardiol.

Coronary

The Skeptics' Guide to EM

SEPTEMBER 11, 2021

Date: September 8th, 2021 Reference: Desch et al. Date: September 8th, 2021 Reference: Desch et al. Defibrillation is the treatment of choice in these cases but does not often result in sustained ROSC ( Kudenchuk et al 2006). Acute coronary syndrome (ACS) is responsible for the majority (60%) of all OHCAs in patients.

Coronary

Critical Care Scenarios

JANUARY 1, 2020

Case files Resources References Champion S, Belcour D, Vandroux D, et al. Case files Image credit: B Boling, personal files Image credit: B Boling, personal files Resources References Champion S, Belcour D, Vandroux D, et al. Ghadri JR, Cammann VL, Jurisic S, Seifert B, Napp LC, Diekmann J, et al. Eur Heart J. 2015;4(2):189-96.

ALS

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. Nikus et al. Kontos et al. Kontos et al. Bischof et al.

STEMI

EMS 12-Lead

MAY 20, 2022

Additional architectural changes include systolic anterior motion of the mitral valve, endothelial dysfunction at the level of the coronary arterial bed, and ventricular diastolic dysfunction. This worried the crew of potential acute coronary syndrome and STEMI was activated pre-hospital. It is spread to V2 and V3. References Naidu, S.

Coronary

Dr. Smith's ECG Blog

APRIL 18, 2024

The ECG is just a test: a Bayesian approach to acute coronary occlusion If a patient with a recent femur fracture has sudden onset of pleuritic chest pain, shortness of breath, and hemoptysis, the D-dimer doesn’t matter: the patient’s pre-test likelihood for PE is so high that they need a CT. Amsterdam et al. Alencar et al.

STEMI

The Skeptics' Guide to EM

JANUARY 18, 2020

Date: January 16th, 2020 Reference: Troponin Testing and Coronary Syndrome in Geriatric Patients With Nonspecific Complaints: Are We Overtesting? Date: January 16th, 2020 Reference: Troponin Testing and Coronary Syndrome in Geriatric Patients With Nonspecific Complaints: Are We Overtesting? Reference: Wang et al.

ACS

EMS 12-Lead

JUNE 20, 2022

One cannot rely on this feature as a means of detecting changes – subtle, or dramatic – for volatile occlusive coronary thrombus. Discussion When the QRS is normal, is the encountered ST/T changes that beget suspicion for LAD ACS (as in both of these cases) the result of occlusive coronary thrombus, or simply a normal variant?

ACS

EMS 12-Lead

AUGUST 22, 2022

The coronary angiogram revealed no critical stenosis, or acute plaque ulceration. Takotsubo should be a diagnosis of exclusion after angiography reveals no obstructive coronary disease, and repeat Echo displays left ventricular recovery. Furthermore, pertinent electrolyte values (e.g. potassium) were within normal parameter.

E-9-1-1

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

Thanks in part to rapid bedside diagnosis, the patient was able to avoid emergent coronary angiography. Consider the following: We become attuned to looking for acute coronary occlusion in patients who present with acute symptoms to the ED ( E mergency D epartment ).

E-9-1-1

EMOttawa

DECEMBER 18, 2023

Methodology: 3/5 Usefulness: 1/5 Georgiopoulos G, et al. The post Modification of the GRACE Risk Score for Risk Prediction in Patients With Acute Coronary Syndromes appeared first on EMOttawa Blog. JAMA Cardiol. Methods: Retrospective.

Coronary

The Skeptics' Guide to EM

MAY 19, 2018

[display_podcast] Date: May 16, 2018 Reference: Freund et al. display_podcast] Date: May 16, 2018 Reference: Freund et al. Reference: Freund et al. 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

Dr. Smith's ECG Blog

MARCH 10, 2025

The latest is Langlois-Carbonneau et al. But like many similar studies, the study was small (one year at one centre with no indication of the incidence of acute coronary occlusion), and it used as the gold standard the final cardiologist interpretation of the ECG - not the patient outcome! But according to Langlois-Carbonneau et al.,

STEMI

ACEP Now

JULY 7, 2023

Extracorporeal membrane oxygenation Of patients with out-of-hospital cardiac arrest presenting to the ED in refractory VF, a majority have significant coronary artery disease, much of which is amenable to percutaneous coronary intervention. References Tsao CW, et al. Benjamin EJ, et al. Kimblad H, et al.

Defibrillator

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

EMS 12-Lead

APRIL 14, 2022

It should be emphasized here that this is a presentation of high-pretest probability for Acute Coronary Syndrome (ACS). link] [1] Zachary et al. Utility of the history and physical examination in the detection of Acute Coronary Syndromes in emergency department patients. Western Journal of Emergency Medicine, 18 (4), 752-760. [2]

ACS

Dr. Smith's ECG Blog

OCTOBER 3, 2024

Coronaries were clean. Not OMI with High Confidence Click here to sign up for Queen of Hearts Access We showed that the Queen of Hearts decreases false positive cath lab activations: 1) Published recently in Prehospital Emergency Care Baker PO et al. 2) To be presented at AHA conference in Chicago in 2 weeks: Sharkey SW et al.

E-9-1-1

The Skeptics' Guide to EM

JUNE 14, 2017

It has been said that it can take 17 years for 14% of research to reach the patients’ bedside ( Morris et al 2011 ). Talk I: Knowledge Translation in the Digital Age The first talk was on knowledge translation (KT) in the digital age. A number of examples of the KT problem were provided.

Coronary