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. ECG 1 What do you think?

Defibrillator

Dr. Smith's ECG Blog

AUGUST 30, 2015

He described the sensation and the sequence of events as a “Hampir Stroke” (Hampir stroke in the Malay Language can be literally translated “Near Stroke,” but colloquially probably means a near catastrophic event, like a Myocardial Infarction.) There were two other small scale events but all three were associated with fever.

STEMI

Dr. Smith's ECG Blog

DECEMBER 6, 2024

Angiogram: Severe two-vessel coronary artery disease of a left dominant system including 70 to 80% stenosis involving the distal left main/bifurcation. Case continued Troponins over 26 hours, from right to left : Echocardiogram: Mild concentric left ventricular wall thickening, normal cavity size, and normal systolic function.

Coronary

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). He was discharged home on anticoagulation.

STEMI

Dr. Smith's ECG Blog

OCTOBER 20, 2018

A 60-something female with no history of coronary disease or myocardial infarction complained to bystanders that she was dizzy, then collapsed from standing. Patient had no memory of event. So what is the proposed sequence of events?

First Responder

ACEP Now

MAY 9, 2025

vs 25%; p=0.31) No difference in thrombotic events (3.6% mcg/kg IV infused over 30 minutes Onset: within 30 minutes Peak effect: 1.5-2 vs 5.1%; RR Feldman E, et al; 2019. vs 21.7%; p=0.475) Changes in ICH volume on repeat CT were smaller in the DDAVP group (0 mL vs 0.7 vs 40.6%; p Desborough M, et al; 2017.

Allergic Reaction

Dr. Smith's ECG Blog

JUNE 15, 2025

The physician was worried about possible acute coronary occlusion, and activated the cath lab. The angiogram showed no significant coronary disease: First troponin I was 10 ng/L. Download now for iOS or Android. Smith and Meyers are shareholders in Powerful Medical.) Second troponin was 23 ng/L.

STEMI

Dr. Smith's ECG Blog

JUNE 19, 2015

He is already on maximal medical therapy prior to presentation, but continues to have recurrent cardiac events. CAD s/p 4 vessel cabg: Last coronary angiogram in 9/2013 showing a severely tortuous abd aorta, unable to engage LIMA. Slight progression of L coronary disease. RCA and vein graft to RCA complete occlusion.

CAD

EMS 12-Lead

APRIL 9, 2024

He denied any specific prodrome of gross palpitations, however did endorse feeling quite dizzy just before the event. Given no clinical prelude of anginal (or equivalent) descriptors, prior to the acute event, risk stratification of the ECG and Troponin was pursued via Echo and nuclear Myocardial Perfusion Imaging (MPI).

Coronary

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

Compensatory enlargement was defined as being present when the total coronary arterial cross-sectional area at the stenotic site was greater than that at the proximal nonstenotic site. Furthermore, if this occurs at all, it is a rare event. 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

Major adverse cardiac event rates in moderate-risk patients: Does prior coronary disease matter? Major adverse cardiac event rates in moderate-risk patients: Does prior coronary disease matter? He has no history of coronary artery disease. Date: June 30th, 2022 Reference: McGinnis et al. AEM June 2022.

Coronary

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

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

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

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

The Skeptics' Guide to EM

JUNE 14, 2017

Thank you to Dr. Manrique Umana for inviting me and the conference organizers for putting on such an amazing and educational event. Thank you to Dr. Manrique Umana for inviting me and the conference organizers for putting on such an amazing and educational event.

Coronary

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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