Dr. Smith's ECG Blog

NOVEMBER 15, 2023

MINOCA may be due to: coronary spasm, coronary microvascular dysfunction, plaque disruption, spontaneous coronary thrombosis/emboli , and coronary dissection; myocardial disorders, including myocarditis, takotsubo cardiomyopathy, and other cardiomyopathies. Thus, intracoronary imaging modalities are crucial in this setting. From Gue at al.

Coronary Angiogram 110

Coronary Angiogram Plaque Thrombosis STEMI 110

Dr. Smith's ECG Blog

JUNE 23, 2024

His ECG at the accepting facility is shown below: Accepting facility ECG The team reviewed his angiography films with an interventionalist and thought they were suspicious for plaque rupture in LAD, but they were not confident. The electrophysiologist is a reader of Dr. Smith's ECG Blog. They consulted EP for evaluation for ICD.

Chest Pain 119

Chest Pain Cardiac Arrest Sudden Cardiac Death Blog 119

Dr. Smith's ECG Blog

APRIL 22, 2024

Angiography : --Culprit for the patient's unstable angina/Wellen syndrome is a ruptured plaque in the mid LAD. --As Despite description of Wellens’ Syndrome over 40 years ago — this syndrome remains misunderstood by all-to-many clinicians ( See My Comment at the bottom of the page in the August 12, 2022 post in Dr. Smith’s ECG Blog ).

Chest Pain 118

Chest Pain Myocardial Infarction Anatomy Angina 118

Dr. Smith's ECG Blog

MAY 20, 2024

This was sent by an undergraduate (not yet in medical school, but applying now) who works as an ED technician (records all EKGs, helps with procedures, takes vital signs) and who reads this blog regularly. Smith comment : Is the ACS (rupture plaque) with occlusion that is now reperfusing? The ST depressions in I and aVL have resolved.

Chest Pain 126

Chest Pain Blood Pressure Ischemia STEMI 126

Dr. Smith's ECG Blog

SEPTEMBER 9, 2024

Smith comment : a very high proportion of MINOCA are ruptured plaque with lysed thrombus. That plaque is at risk of thrombosing again. It is worthwhile remembering that the majority of plaques which rupture are non-obstructive before they ulcerate and thrombose. Most plaque is outside the lumen!!

Plaque 67

Plaque Stents Stent Chest Pain 67

Dr. Smith's ECG Blog

SEPTEMBER 22, 2023

The first troponin was 21 ng/L (detectable but below the 99% URL of 35 ng/L).

STEMI 131

STEMI Stenosis Plaque Chest Pain 131

Dr. Smith's ECG Blog

DECEMBER 7, 2023

Learning Points: Type 1 MI is the type we are most familiar with: rupture of atherosclerotic plaque with production thrombus or platelet fibrin aggregates. You also appreciate the overly upright T waves in I and aVL which are reciprocal to the inferior T waves. But not all OMI is atherosclerotic in nature.

SCAD 125

SCAD Ischemia Coronary Artery Disease Cardiomyopathy 125

Dr. Smith's ECG Blog

MARCH 17, 2024

ECG 1 Readers of this blog will have no trouble recognizing this as an OMI with some early reperfusion. Possible etiologies (depending on your definition) include: plaque rupture with spontaneous recanalization, coronary artery vasospasm, spontaneous coronary artery dissection, or other rarer causes. < 0.033). His ECG is shown.

Angina 71

Angina Chest Pain Blog Ischemia 71

Dr. Smith's ECG Blog

JULY 11, 2024

Because: 1) He has been reading this blog for a long time. The scan did not find PE, but showed evidence of coronary plaque: There are areas of dense white in the LAD (red and blue circles) and in the first diagonal (green circle). This is another case sent by the undergraduate (who is applying to med school) who works as an EKG tech.

Outcomes 113

Outcomes Stenosis Outpatient Echocardiogram 113

Dr. Smith's ECG Blog

MARCH 22, 2024

And finally, after placement of a stent in the LAD: Before and after: (Unfortunately, this resulted in the "jailing" of the septal branches behind the stent and probably some degree of plaque shift which is why they do not opacify well in the "after" shot. This was the cost of preventing infarction of the anterior wall.) ng/mL (ref.

Chest Pain 115

Chest Pain STEMI Bradycardia Ischemia 115

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

To prove there is no plaque rupture, you need to do intravascular ultrasound (IVUS). An angiogram is a "lumenogram;" most plaque is EXTRALUMINAL!! One of the most common is rupture of a non-obstructive plaque, with thrombus formation and OMI that spontaneously lyses and leaves a wide open artery. It can only be seen by IVUS.

Plaque 52

Plaque Chest Pain Thrombosis Stenosis 52

Dr. Smith's ECG Blog

MAY 19, 2020

If the arrest was caused by acute MI due to plaque rupture, then the diagnosis is MINOCA. Here is my comment on MINOCA: "Non-obstructive coronary disease" does not necessarily imply "no plaque rupture with thrombus." They often cannot even be recognized as culprits, as fissured or ulcerated plaque. FFR can be useful.

Defibrillator 52

Defibrillator Circulation Plaque Cardiac Arrest 52

Dr. Smith's ECG Blog

OCTOBER 20, 2024

There are multiple possible clinical situations that could account for diffuse subendocardial ischemia that is not due to ACS and plaque rupture. The history in today's case with sudden loss of consciousness followed by chest pain is very suggestive of ACS and type I ischemia as the cause of the ECG changes.

Cardiogenic Shock 129

Cardiogenic Shock Ischemia Chest Pain Cardiac Arrest 129

Dr. Smith's ECG Blog

NOVEMBER 9, 2023

Ramus: There is a large caliber branching ramus intermediate LAD is a medium caliber vessel that extends to the apex and is noted to have diffuse mild to moderate plaque in the midsegment. Post Procedure TIMI III. D1 is a medium caliber vessel, distal diagonal branches are small in caliber Echocardiogram Normal LV cavity size and thickness.

Chest Pain 78

Chest Pain Echocardiogram Blog Ischemia 78

MIBHS

DECEMBER 27, 2024

In this blog, well explore why anemia can occur after heart bypass surgery, how common it is, and how it can be managed. This condition occurs when the blood vessels that supply blood to the heart become blocked or narrowed by plaque buildup. It can also be considered a postoperative complications may hinder recovery.

Coronary Artery Bypass Graft 52

Coronary Artery Bypass Graft Open-Heart Surgery Kidney Disease Chronic Disease 52

AMS Cardiology

NOVEMBER 4, 2023

At AMS Cardiology we understand the significance of proactive care; that’s why we’ve put together this blog where we’ll explore the essential aspects of peripheral artery disease prevention and management. Medications – Medications play a crucial role in managing PAD symptoms.

Peripheral Arterial Disease 52

Peripheral Arterial Disease Blood Pressure Diet Exercise 52

Dr. Smith's ECG Blog

JANUARY 15, 2024

ECG 2 Especially in the context of the first ECG, readers of this blog will readily appreciate the ST elevations and hyperacute T waves in II, III, aVF, V6, and to a lesser extent V5. As an aside, the LCx OMI is a type 2 event, since it is due to supply-demand mismatch from thrombus, and not due to atherosclerotic plaque rupture or erosion).

Chest Pain 64

Chest Pain Blog Arrhythmia Critical Care 64

Dr. Sanjay Gupta

DECEMBER 19, 2022

With time, fat and cholesterol can get trapped in the areas of wear and tear and cause plaque formation. The plaques can damage us in 2 ways. Firstly the plaque may continue to build up and cause actually restrict blood from getting to the heart muscle and this often presents with symptoms of chest tightness on exertion or angina.

Heart Rhythm 40

Heart Rhythm Plaque Heart attacks Heart Attack 40

MIBHS

OCTOBER 15, 2024

In this blog, we’ll break down the steps of coronary circulation, helping you understand how your heart maintains its own health while keeping the rest of the body alive and well. This is where coronary circulation comes into play. Any interruption in this process can result in serious consequences.

Circulation 52

Circulation Heart attacks Heart Attack Chest Pain 52

Dr. Malcolm Kendrick

AUGUST 26, 2022

link] For those who have read my blog assiduously, or have read ‘The Clot Thickens’, none of this is new, or any surprise. The thrombogenic hypothesis, that endothelial damage and subsequent clot formation underlies the formation and growth of plaques, may represent a better model for ASCVD. Anyway, here it is. Here is the abstract.

Cardiovascular Disease 40

Cardiovascular Disease Cholesterol Article Plaque 40

Dr. Smith's ECG Blog

DECEMBER 14, 2022

Reperfusion of OMI indicates at least partial thrombolysis of occluding thrombus, but still unstable plaque rupture, which can reocclude at any moment. This case's first EMS ECG shows a rare example of LVH with active anterior and high lateral OMI. Comparison to prior ECG can be very helpful.

Chest Pain 52

Chest Pain STEMI Blog Stenosis 52

BoardVitals - Cardiovascular

FEBRUARY 10, 2020

The diagnostic criteria of stress cardiomyopathy includes the presence of transient regional wall motion abnormalities (typically not in a single coronary distribution), absence of angiographic evidence of obstructive coronary disease/acute plaque rupture, with presence of new electrocardiographic abnormalities or modest troponin elevation.

Cardiomyopathy 52

Cardiomyopathy Chest Pain Heart attacks Heart Attack 52

Dr. Smith's ECG Blog

JULY 11, 2018

Today, they viewed the angiogram and concluded that the thrombus at the mid RCA must have extended proximally from the culprit ruptured plaque, extending proximal to the RV marginal branch and temporarily occluding it. 24, 2018 ECG Blog — Please scroll down to the bottom of the page to My Comment, in the section "Beyond-the-Core". ).

Chest Pain 52

Chest Pain STEMI Ischemia Blog 52

Dr. Smith's ECG Blog

FEBRUARY 20, 2009

There was a ruptured plaque with thrombus in the LAD, with some flow still (accounting for the inverted T waves). Another EKG was done at 0739: (#5) This shows even more ST elevation. The patient was still asymptomatic. An initial troponin returned at 12 ng/ml. The cath lab was activated.

Chest Pain 52

Chest Pain STEMI Ischemia Plaque 52

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

Therefore it means acute type 1 ACS plaque rupture with impeded flow and impending full occlusion until proven otherwise. While subendocardial ischemia pattern can be due to any possible reason for supply/demand mistmatch in infinite clinical scenarios, this patient's scenario was acute chest pain consistent with ACS.

Chest Pain 83

Chest Pain Cardiogenic Shock Ischemia Myocardial Infarction 83

Dr. Smith's ECG Blog

OCTOBER 24, 2018

This was diagnosed by IVUS (intravascular ultrasound) as a ruptured plaque. As there was ruptured plaque, this is NOT Prinzmetal's angina. It is just as dangerous, as there is a ruptured plaque with thrombus (which lysed) in the proximal LAD. Values: STE60V3 = 2.0, QRS V2 = 10, RAV4 = 15.5, There was good flow. It was stented.

STEMI 40

STEMI Angina Myocardial Infarction Plaque 40

Dr. Smith's ECG Blog

OCTOBER 24, 2019

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. Angiography Angiography was performed after aspirin and heparin were started.

Chest Pain 52

Chest Pain SCAD STEMI Cardiogenic Shock 52

Dr. Smith's ECG Blog

SEPTEMBER 20, 2011

The ECG and ultrasound could not have been differentiated from acute plaque rupture with occlusion of the RCA. So this is classic inferoposterior STEMI on the ECG but is NOT acute coronary syndrome! This could not have been known without the angiogram.

Cardiac Arrest 52

Cardiac Arrest STEMI Ultrasound Chest Pain 52

Dr. Smith's ECG Blog

APRIL 12, 2023

Mild Plaque no angiographically significant obstructive coronary artery disease. I looks as if there has been reperfusion. PM Cardio AI Bot: Not OMI with high confidence Angiogram: Speckle Tracking of Acute Pulm Edema.MOV from Stephen Smith on Vimeo.

Echocardiogram 52

Echocardiogram Pulmonary Cardiomyopathy Coronary Artery Disease 52

Dr. Smith's ECG Blog

APRIL 8, 2022

The ECG is diagnostic for acute transmural infarction of the anterior and lateral walls, with LAD OMI being the most likely cause (which has various potential etiologies for the actual cause of the acute coronary artery occlusion, the most common of which is of course type 1 ACS, plaque rupture with thrombotic occlusion).

Chest Pain 52

Chest Pain SCAD STEMI Blog 52

Dr. Sanjay Gupta

DECEMBER 19, 2022

She had some very minor plaque but certainly nothing that could explain the heart attack and therefore she was discharged with a diagnosis of MINOCA i.e She agreed and we performed an angiogram and we were fully expecting a blockage but interestingly there weren’t any.

Heart attacks 40

Heart attacks Heart Attack Blood Clot Chest Pain 40

AMS Cardiology

AUGUST 15, 2023

High cholesterol levels – Elevated levels of bad cholesterol can contribute to plaque buildup in your arteries, increasing the risk of heart disease. Routine blood pressure checks are essential to maintaining a healthy heart as high blood pressure often has no symptoms.

Heart Disease 52

Heart Disease Blood Pressure Risk Factors Cholesterol 52

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

We’ve presented many variations on this theme on Dr. Smith’s Blog — with today’s case being distinguished by its discovery on abdominal exam ! For more on “My Take” for a systematic approach to ECG interpretation — Please check out My Comment at the bottom of the page in the October 17, 2022 post in Dr. Smith’s ECG Blog.

Ischemia 52

Ischemia STEMI Stenosis Chest Pain 52

Dr. Smith's ECG Blog

JANUARY 9, 2023

Only after her troponin peaked at 500,000 ng/L did she get her angiogram, which showed a 100% left main occlusion due to ruptured plaque. Young people can suffer acute coronary occlusion, whether by typical atherosclerotic plaque rupture, or by coronary anomalies, coronary aneurysms, dissections, spasm, etc. Diagnostic of Massive OMI.

Chest Pain 52

Chest Pain Aneurysm STEMI Thrombosis 52

Dr. Smith's ECG Blog

DECEMBER 23, 2022

Acute MI due to plaque rupture does happen in young people, including young women. Artificial intelligence (Convolutional Deep Neural Networks) will be able to discern this subtle information. Beware a low HEART score. It is only meaningful if you can accurately interpret the ECG. Here are 11 cases of young women with acute MI.

Chest Pain 52

Chest Pain Critical Care STEMI Plaque 52

Dr. Smith's ECG Blog

DECEMBER 10, 2019

Dr. Punjabi has a fantastic radiology blog on Spectral CT: [link] A negative CT should not be relied upon to rule out ischemia. But young people do have MI, due to anomalous coronary arteries, coronary artery dissection, Kawasaki dz, even atherosclerotic plaque rupture, and other etiologies. Under 20, myocarditis is far more likely.

Chest Pain 52

Chest Pain Pericarditis Ischemia Pediatrics 52

Dr. Smith's ECG Blog

MARCH 9, 2017

For example, a coronary plaque ruptures: the vessel can undergo occlusion, spontaneous reperfusion, maybe reocclusion, again reperfusion, etc. If this patient was discharged from the ED she very likely would have died. We must be the experts and pick up these life-saving ECG findings! ACS can be a very dynamic process.

Chest Pain 52

Chest Pain Angina Ischemia Plaque 52