2019, Ischemia and Stent - Cardiovascular Update

Abstract WP242: Comparison Between Right and Left Transradial Approach for Carotid Artery Stenting Using a 6-French Simmons Guiding Sheath

Stroke Journal

JANUARY 30, 2025

To our knowledge, no studies have directly compared the right and left TRA for carotid artery stenting (CAS). The right TRA was performed as a first-line approach from 2019 to 2021, with the left TRA being used thereafter. All carotid stenoses were successfully dilated.

Stent

Stent Stents Aortic Interventional Cardiology

Wide complex and apparent hyperacute T-waves. Does absence of change from previous ECG mean that it is not New?

Dr. Smith's ECG Blog

NOVEMBER 5, 2023

ECG#1 Assessing ischemia on an ECG with wide QRS complexes (AIVR, ventricular pacing, BBB, etc) can be challenging. Many health care providers will simply not attempt to assess ischemia in the presence of a wide QRS. In the ECG above there are several features indicative of ongoing transmural ischemia. What do you think?

Chest Pain

Chest Pain Pacemaker Ischemia Stent

Three prehospital ECGs in patients with chest pain

Dr. Smith's ECG Blog

AUGUST 6, 2024

In any case, the ECG is diagnostic of severe ischemia and probably OMI. So this could be myocarditis but in my opinion needs an angiogram before making that diagnosis. == Dr. Nossen Comment/Interpretation: Evaluation of ischemia on an ECG can be very challenging. Concordant STE of 1 mm in just one lead or 2a.

Chest Pain

Chest Pain Ischemia Pericarditis Tachycardia

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What do you think the echocardiogram shows in this case?

Dr. Smith's ECG Blog

MAY 13, 2020

Here is the EMS ECG: Obviously massive diffuse subendocardial ischemia, with profound STD and STE in aVR Of course this pattern is most often seen from etoliogies other than ACS. The ECG only tells you there is ischemia, not the etiology of it. Nevertheless, the clinical situation made other etiologies unlikely.

Echocardiogram

Echocardiogram Ischemia Chest Pain Blog

A fascinating electrophysiology case. What is this wide complex tachycardia, and how best to manage it?

Dr. Smith's ECG Blog

JANUARY 9, 2024

The patient is female in her 80s with a medical hx of previous MI with PCI and stent placement. Are you confident there is no ischemia? Primary VT , and the VT with tachycardia is causing ischemia with chest discomfort (supply-demand mismatch/type 2 MI)? The last echocardiography 12 months ago showed HFmrEF.

Tachycardia

Tachycardia Electrophysiology Atrial Flutter Ischemia

Abstract 254: Imaging Findings of Stroke Following Treatment of Ruptured Cerebral Aneurysm Increases Risk of Postoperative Delirium

Stroke: Vascular and Interventional Neurology

NOVEMBER 9, 2023

5 ICSS‐ MRI study (International Carotid Stenting Study Magnetic Resonance Imaging Study), indicated that patients with periprocedural hemodynamic depression had decreased cerebral blood flow and increased the risk of new lesions in imaging.6 This is secondary to delayed postoperative cerebral ischemia and infarction caused by vasospasm.7

Aneurysm

Aneurysm Stroke Strokes Ischemia

7 steps to missing posterior Occlusion MI, and how to avoid them

Dr. Smith's ECG Blog

JANUARY 3, 2022

It was a 60yo with a history of stents to the circumflex and right coronary arteries, who presented with 9 hours of fluctuating central chest pain. 2] Here there is no posterior ST elevation, but the anterior ST depression is also less—so it is dynamic, confirming acute ischemia. But it is still STEMI negative.

STEMI

STEMI Myocardial Infarction Chest Pain Ischemia

Cath Lab occupied. Which patient should go now (or does only one need it? Or neither?)

Dr. Smith's ECG Blog

OCTOBER 15, 2024

A prehospital “STEMI” activation was called on a 75 year old male ( Patient 1 ) with a history of hyperlipidemia and LAD and Cx OMI with stent placement. Whether these EKGs show myocarditis, a normal variant, or something else, they are overall not typical of transmural ischemia of the anterior or high lateral walls. It was stented.

Chest Pain

Chest Pain STEMI Echocardiogram Stent

Something Winter This Way Comes

EMS 12-Lead

AUGUST 14, 2022

One stent was deployed with restorative TIMI-0 flow. Accurate identification is absolutely necessary as this pattern can be easily misinterpreted for something less nefarious: for example, generic “subendocardial ischemia.” However, when the Troponin I returned 8.4 The red arrow shows a 90% LAD occlusion at the D1 branch.

STEMI

STEMI Sudden Cardiac Death Thrombosis Thrombolysis

Hypertrophic Cardiomyopathy

EMS 12-Lead

MAY 20, 2022

There is broad subendocardial ischemia as demonstrated by STE aVR with concomitant STD that almost appears appropriately maximal in Leads II and V5. There is LBBB-like morphology with persistent patterns of subendocardial ischemia. A mid-LAD culprit lesion was identified and stented. References Naidu, S. Tower-Rader, A.

Cardiomyopathy

Cardiomyopathy Ischemia STEMI Coronary Angiogram

A 40-something healthy male with transient chest squeezing

Dr. Smith's ECG Blog

SEPTEMBER 22, 2019

Troponin profile The patient underwent angiography and had a 90% thrombotic proximal LAD lesion that was stented. This patient's ischemia was so brief that it did not cause any myocardial stunning. This patient's ischemia was so brief that it did not cause any myocardial stunning.

Chest Pain

Chest Pain Ischemia STEMI Stent

Inferior Subtle ST elevation: straight ST segment, but also no reciprocal ST depression in aVL: which is more important?

Dr. Smith's ECG Blog

JUNE 28, 2019

60-something with h/o MI and stents presented with chest pain radiating to the back and nausea/vomiting. It was stented. The patient had a p rior h istory of MI + stents. More likely, these T waves probably reflect ischemia of uncertain age. Time zero What do you think? There is inferior ST elevation. Pericarditis?

Chest Pain

Chest Pain Pericarditis Stent Stents

Chest pain with NonDiagnostic ECG but Diagnostic CT Scan

Dr. Smith's ECG Blog

SEPTEMBER 27, 2019

This transmural ischemia, but not necessarily completed infarction (yet). See more images of this case at Gopal's Spectral CT Blog: It's all about confidence With continued symptoms, an elevated troponin, and no other explanation, this is acute MI with ongoing ischemia until proven otherwise.

Chest Pain

Chest Pain Blog Ischemia Article

Acute Chest pain in a 50-something, and a "Normal" ECG

Dr. Smith's ECG Blog

AUGUST 17, 2019

It could at least say: "ST Elevation, consistent with normal variant," or "consistent with ischemia or normal variant," or "consistent with early repolarization." Some normal STE is not due to ischemia at all. 100% proximal LAD successfully stented. But it simply says "normal." Some patient's baseline ECG has zero STE.

Chest Pain

Chest Pain STEMI Blog Ischemia

5 Cardiologists said this is not a STEMI. But was it an OMI?

Dr. Smith's ECG Blog

AUGUST 15, 2019

They found 100% acute mid-LAD Occlusion MI, stented with excellent angiographic result. Ongoing ischemia (by symptoms, ECG, or troponin) despite maximal medical management is an indication for emergent cath lab activation. == MY Comment by K EN G RAUER, MD ( 8/15/2019 ): == Once again, the w rong q uestion was a sked in this case.

STEMI

STEMI Chest Pain Risk Factors Anatomy

An ECG with only «marginal» change

Dr. Smith's ECG Blog

DECEMBER 15, 2023

In other words, the inferior ST segments in the first ECG show more straightening which is more concerning for ischemia. The culprit lesion was opened and stented. For more on this mirror-image opposite ST-T wave relation in leads III vs aVL — See My Comment in the March 8, 2019 and August 9, 2018 posts in Dr. Smith's ECG Blog ).

Chest Pain

Chest Pain Blog Ischemia Risk Factors

The Advantages Of A CT Coronary Angiogram

Dr. Paddy Barrett

AUGUST 1, 2023

This is where careful discussion with the patient is required, and an explanation of the most recent literature suggests no reduction in future major heart events with stenting in most obstructive coronary artery disease 5. ( 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. 5 ISCHEMIA Research Group.

Coronary Angiogram

Coronary Angiogram Plaque Coronary Artery Disease Chest Pain

Opiate overdose, without chest pain or shortness of breath. Cognitive dissonance.

Dr. Smith's ECG Blog

NOVEMBER 1, 2022

The 50-something patient with history of coronary stenting and slightly reduced LV ejection fraction. In the setting of prior stenting and reduced left ventricular ejection fraction, would pursue a heart team revascularization approach Syntax score 28.5, This alone could be due to LVH, but V4 could NOT be due to LVH.

Chest Pain

Chest Pain Coronary Artery Bypass Graft Pericarditis Blog

A man in his 70s with chest pain during a bike ride

Dr. Smith's ECG Blog

SEPTEMBER 30, 2019

These findings are concerning for inferior wall ischemia with possible posterior wall involvement. Slow TIMI 2 initially with brisk flow status post percutaneous coronary intervention with 18mm drug-eluting stent. The morphology in V2 is also concerning and it appears that the ST segment is being pushed down, as in ST depression.

Chest Pain

Chest Pain Pulmonary ACE Inhibitor Pacemaker

A 40 year old man with chest pain since last night

Dr. Smith's ECG Blog

JULY 11, 2019

100% proximal LAD thrombotic occlusion with TIMI 0 flow was found and stented with excellent angiographic result and TIMI 3 flow. When in doubt, record serial ECGs and watch out for signs of ischemia despite medical management. == Comment by K EN G RAUER, MD ( 7/11/2019 ): == Our thanks to Drs. Cath images: Before intervention.

Chest Pain

Chest Pain STEMI Blog Stent

A 50-something with 5 hours of typical chest pain and Left Bundle Branch Block

Dr. Smith's ECG Blog

DECEMBER 16, 2019

Chest pain with New LBBB: It helps to actually measure the ST/S ratio A Fascinating Demonstration of ST/S Ratio in LBBB and Resolving LAD Ischemia The cath lab was activated. It was opened and stented. link] == MY Comment, by K EN G RAUER, MD ( 12/17/2019 ): == Great case about some subtleties in association with LBBB.

Chest Pain

Chest Pain Myocardial Infarction Stent Stents

A 40-Something male with a "Seizure," Hypotension, and Bradycardia

Dr. Smith's ECG Blog

OCTOBER 7, 2019

RCA ischemia often results in sinus bradycardia from vagal reflex or ischemia of the sinus node. He was successfully stented. Smith pointed out that while atropine may may result in slightly more oxygen demand, the increase in cardiac output and in blood pressure would increase overall coronary perfusion and decrease ischemia.

Bradycardia

Bradycardia Cardiogenic Shock STEMI Ischemia

Should Troponin be a Vital Sign? Perhaps, but only if Interpreted Using Pre-test Probability.

Dr. Smith's ECG Blog

FEBRUARY 5, 2019

distal stent patent. Given our concern about possible subtle high-lateral OMI — this raises the question whether the upright T waves in leads V1 and V2 of this 1st ECG might be abnormal and reflect ischemia. Repeat ECG shows modest ST elevation in I and aVL and depression in inferior leads." The cath lab was activated.

Myocardial Infarction

Myocardial Infarction Chest Pain Cardiogenic Shock STEMI

Acute chest pain with LBBB and obvious OMI, worsening on serial ECGs, but repeatedly missed by physicians and Marquette 12SL

Dr. Smith's ECG Blog

JANUARY 23, 2025

His triage EKG is shown below: There is left bundle branch block, so the EKG must be evaluated for ischemia by Smith-modified Sgarbossa criteria. There is evidence of transmural ischemia of the posterior wall as well. Leads V1 to V4 have down-up shaped T waves typical of ischemia and atypical of LBBB.

Chest Pain

Chest Pain Ischemia STEMI Blog

"Anterior" ST Depression: Which Lesion is the Culprit?

Dr. Smith's ECG Blog

MARCH 9, 2025

It is not clear by her note what she meant by this (whether or not she recognized this EKG as diagnostic of transmural ischemia, and if so, of what territory) but emergent reperfusion therapy was not pursued. The proximal and mid LAD stenoses were stented and the OM 2 was left alone. Subendocardial ischemia does not localize.

Ischemia

Ischemia Blog STEMI Coronary Angiogram

Carotid web : No longer a new kid in stroke risk

Dr. S. Venkatesan MD

JANUARY 14, 2025

Pasarikovski, Neurology: Clinical Practice 2019 How does it appear in carotid angiogram and in real time per-operative ? Management The web can create a flow disturbance, potentiating local thrombus formation, which can embolize producing resulting in cerebral ischemia. Christopher R. Reference 1.Rainer Rainer W.G., Cramer G.G.,

Stroke

Stroke Strokes Ischemia Embolism

One of those ECGs you need to instantly recognize, which learners may struggle with at first

Dr. Smith's ECG Blog

JANUARY 11, 2025

He had undergone stenting of the LAD several weeks ago (unclear whether elective for stable symptoms, or in response to acute coronary syndrome). That the chief complaint of today's patient was acute CP ( C hest P ain ) with a history of known coronary disease and LAD stent placement a few weeks earlier. He appeared critically ill.

Cardiogenic Shock

Cardiogenic Shock Chest Pain Tachycardia Cardiac Arrest

Chest (or abdominal?) pain and ECG artifact.

Dr. Smith's ECG Blog

NOVEMBER 23, 2024

It was opened and stented. Compared to TTE from 7/3/24: the anterior regional wall motion abnormality is new and is consistent with ischemia/infarction in the LAD territory == MY Comment , by K EN G RAUER, MD ( 11/20 /2024 ): == There are several insightful aspects of today's case. The August 26, 2019 post — baseline artifact.

Blog

Blog Chest Pain Myocardial Infarction Critical Care

Patient is informed of her husband's death: is it OMI or it stress cardiomyopathy?

Dr. Smith's ECG Blog

MARCH 8, 2025

After stent deployment, we often see improvement in the ST-T within seconds or minutes. Here is the final angiogram following placement of a stent in the ostial RCA. 2:04 PM, post stent deployment You can see that even after complete restoration of flow, the ECG still looks terrible, V most of all.

Cardiomyopathy

Cardiomyopathy Myocardial Infarction Defibrillator Bradycardia

Abstract WP242: Comparison Between Right and Left Transradial Approach for Carotid Artery Stenting Using a 6-French Simmons Guiding Sheath

Wide complex and apparent hyperacute T-waves. Does absence of change from previous ECG mean that it is not New?

Three prehospital ECGs in patients with chest pain

Webinars

What do you think the echocardiogram shows in this case?

A fascinating electrophysiology case. What is this wide complex tachycardia, and how best to manage it?

Abstract 254: Imaging Findings of Stroke Following Treatment of Ruptured Cerebral Aneurysm Increases Risk of Postoperative Delirium

7 steps to missing posterior Occlusion MI, and how to avoid them

Cath Lab occupied. Which patient should go now (or does only one need it? Or neither?)

Something Winter This Way Comes

Hypertrophic Cardiomyopathy

A 40-something healthy male with transient chest squeezing

Inferior Subtle ST elevation: straight ST segment, but also no reciprocal ST depression in aVL: which is more important?

Chest pain with NonDiagnostic ECG but Diagnostic CT Scan

Acute Chest pain in a 50-something, and a "Normal" ECG

5 Cardiologists said this is not a STEMI. But was it an OMI?

An ECG with only «marginal» change

The Advantages Of A CT Coronary Angiogram

Opiate overdose, without chest pain or shortness of breath. Cognitive dissonance.

A man in his 70s with chest pain during a bike ride

A 40 year old man with chest pain since last night

A 50-something with 5 hours of typical chest pain and Left Bundle Branch Block

A 40-Something male with a "Seizure," Hypotension, and Bradycardia

Should Troponin be a Vital Sign? Perhaps, but only if Interpreted Using Pre-test Probability.

Acute chest pain with LBBB and obvious OMI, worsening on serial ECGs, but repeatedly missed by physicians and Marquette 12SL

"Anterior" ST Depression: Which Lesion is the Culprit?

Carotid web : No longer a new kid in stroke risk

One of those ECGs you need to instantly recognize, which learners may struggle with at first

Chest (or abdominal?) pain and ECG artifact.

Patient is informed of her husband's death: is it OMI or it stress cardiomyopathy?

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