Dr. Smith's ECG Blog

NOVEMBER 19, 2016

Smith comment: This patient did not have a bedside ultrasound. Had one been done, it would have shown a feature that is apparent on this ultrasound (however, this patient's LV function would not be as good as in this clip): This is recorded with the LV on the right. What should be done? Should the cath lab be activated?

Ischemia 40

Ischemia Cardiogenic Shock Aortic Stenosis 40

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

This suggests further severe ischemia. The problem is difficult to study because angiographic visualization of arteries is not perfect, and not all angiograms employ intravascular ultrasound (IVUS) to assess for unseen plaque or for plaque whose rupture and ulceration cannot be seen on angiogram. And yet the arteries remain open.

Coronary Angiogram 109

Coronary Angiogram Plaque Thrombosis STEMI 109

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. This was a point of care ultrasound, not a bubble contrast echo. NTG drip started.

Echocardiogram 52

Echocardiogram Ischemia Chest Pain Blog 52

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

His response: “subendocardial ischemia. Smith : It should be noted that, in subendocardial ischemia, in contrast to OMI, absence of wall motion abnormality is common. With the history of Afib, CTA abdomen was ordered to r/o mesenteric ischemia vs ischemic colitis vs small bowel obstruction. Anything more on history?

Ischemia 52

Ischemia STEMI Stenosis Chest Pain 52

Dr. Smith's ECG Blog

JANUARY 6, 2023

I do not think this ECG is by itself diagnostic of OMI (full thickness, subepicardial ischemia ), b ut comparison to a previous might reveal this ECG as diagnostic of OMI. Association between opioid analgesia and delays to cardiac catheterization of patients with occlusion Myocardial Infarctions. Abstract 556.

Chest Pain 52

Chest Pain Ischemia Myocardial Infarction ICU 52

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

This case was provided by Spencer Schwartz, an outstanding paramedic at Hennepin EMS who is on Hennepin EMS's specialized "P3" team, a team that receives extra training in advanced procedures such as RSI, thoracostomy, vasopressors, and prehospital ultrasound. Takotsubo is a sudden event, not one with crescendo angina. Learning Points: 1.

Plaque 52

Plaque Chest Pain Thrombosis Stenosis 52

Dr. Smith's ECG Blog

OCTOBER 24, 2019

This strongly suggests reperfusing RCA ischemia. Troponins, echocardiogram An echocardiogram showed inferobasilar hypokinesis, further supporting a diagnosis of regional ischemia , likely of the area supplied by the RCA. Often, intravascular ultrasound or intravascular optical coherence tomography is requeried to make the diagnosis.

Chest Pain 52

Chest Pain SCAD STEMI Cardiogenic Shock 52

Dr. Smith's ECG Blog

JANUARY 23, 2023

Ischemic ST-Segment Depression Maximal in V1-V4 (Versus V5-V6) of Any Amplitude Is Specific for Occlusion Myocardial Infarction (Versus Nonocclusive Ischemia). J Am Heart Assoc. 2021 Dec 7;10(23):e022866. doi: 10.1161/JAHA.121.022866. 121.022866. Epub 2021 Nov 15.

Chest Pain 52

Chest Pain Blog Stenosis Myocardial Infarction 52

Dr. Smith's ECG Blog

NOVEMBER 3, 2017

Electrocardiographic Differentiation of Early Repolarization FromSubtle Anterior ST-Segment Elevation Myocardial Infarction. To me, this makes the ECG nearly diagnostic of ischemia, though if it is LAD occlusion, there should be ST depression in III and aVL, so it is a bit confusing. Annals of Emergency Medicine 2012;60:45-56.

Chest Pain 52

Chest Pain STEMI Bradycardia Stenosis 52

Circulation

FEBRUARY 12, 2024

The 2 coprimary outcomes were target lesion revascularization and myocardial infarction. The secondary outcomes included ischemia-driven target lesion revascularization, target vessel myocardial infarction, death, cardiac death, target vessel revascularization, stent thrombosis, and major adverse cardiac events.

Ultrasound 67

Ultrasound Myocardial Infarction Thrombosis Stents 67

Dr. Smith's ECG Blog

AUGUST 9, 2024

However the patient continued to have chest pain and bedside ultrasound showed hypokinesis of the septum with significantly reduced LVEF. AIVR is not always the result of significant pathology, but is classically associated with the reperfusion phase of acute myocardial infarction. Do not treat AIVR. References: Ferrier, G.

Chest Pain 106

Chest Pain Arrhythmia Myocardial Infarction STEMI 106

DAIC

APRIL 2, 2025

and European societal guidelines that intravascular imaging with either optical coherence tomography (OCT) or intravascular ultrasound (IVUS) should be routinely used during complex coronary stent procedures, s ays first authorGregg W. These results extend the strong recommendations from recent U.S.

Stent 40

Stent Stents Outcomes Coronary Angiogram 40

Dr. Smith's ECG Blog

APRIL 8, 2016

Bedside ultrasound showed no effusion and moderately decreased LV function, with B-lines of pulmonary edema. If there is polymorphic VT with a long QT on the baseline ECG, then generally we call that Torsades, but Non-Torsades Polymorphic VT can result from ischemia alone. He was managed medically with Clopidogrel. 1987;147(3):465-469.

STEMI 52

STEMI Myocardial Infarction Cardiac Arrest Arrhythmia 52

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

A bedside cardiac ultrasound was normal, with no effusion. Clin Chem [Internet] 2020;Available from: [link] Smith mini-review: Troponin in Emergency Department COVID patients Cardiac Troponin (cTn) is a nonspecific marker of myocardial injury. Myocardial Infarction Type 2 and Myocardial Injury. 3–8 Shi et al.

Cardiac Arrest 52

Cardiac Arrest COVID-19 Myocardial Infarction Cardiogenic Shock 52

Dr. Smith's ECG Blog

JULY 21, 2024

Troponin T peaked at 38,398 ng/L ( = a very large myocardial infarction, but not massive-- thanks to the pre-PCI spontaneous reperfusion, and rapid internvention!! ). There is no definite evidence of acute ischemia. (ie, Some residual ischemia in the infarct border might still be present.

Arrhythmia 131

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 131

Dr. Smith's ECG Blog

SEPTEMBER 29, 2018

Normally, concavity in ST segments suggests absence of anterior ischemia (though concavity by itself is not reassuring - see this study ). His ED cardiac ultrasound (which is not at all ideal for detecting wall motion abnormalities, and is also very operator dependent for this finding) was significant for depressed global EF.

Chest Pain 52

Chest Pain Myocardial Infarction Cardiac Arrest Ischemia 52

Dr. Smith's ECG Blog

OCTOBER 24, 2018

This was diagnosed by IVUS (intravascular ultrasound) as a ruptured plaque. Therefore, this does not meet the definition of myocardial infarction ( 4th Universal Definition of MI ), which requires at least one troponin above the 99% reference range. First, the name (Myocardial Infarction or Not) is not important.

STEMI 40

STEMI Angina Myocardial Infarction Plaque 40

Dr. Smith's ECG Blog

OCTOBER 2, 2021

This proves that the first one was, surprisingly, due to ischemia!! After rethinking the case, he remained concerned about ACS and subsequently performed a point-of-care ultrasound in order to evaluate for regional wall motion abnormality. A second troponin had been drawn 3 hours after arrival and was again less than 0.30ng/mL.

Chest Pain 52

Chest Pain Ultrasound STEMI Myocardial Infarction 52

Dr. Smith's ECG Blog

OCTOBER 7, 2019

RCA ischemia often results in sinus bradycardia from vagal reflex or ischemia of the sinus node. They did not have an ultrasound on the ambulance (some local crews are starting to utilize POC limited US in our service areas). Case continued EMS immediately transported, activated the cath lab and gave 324 mg aspirin en route.

Bradycardia 40

Bradycardia Cardiogenic Shock STEMI Ischemia 40

Dr. Smith's ECG Blog

APRIL 3, 2019

“Appearance of Abnormal Q Waves Early in the Course of Acute Myocardial Infarction: Implications for Efficacy of Thrombolytic Therapy.” These ultrasounds confirm LAD occlusion. Pain will resolve with completed infarct or with resolution of ischemia. This looks like infarct completion. Learning Points: 1.

STEMI 40

STEMI Chest Pain Ischemia Aneurysm 40

Dr. Smith's ECG Blog

JANUARY 28, 2012

The patient might be having cardiac ischemia, but if he is, it is unstable angina or non-STEMI, or perhaps he has not YET pseudonormalized, so serial ECGs may be important. Differential of peri-infarct pericardial fluid The differential includes 1) pericarditis with effusion or 2) hemopericardium. This is normal for these patients.

Chest Pain 40

Chest Pain STEMI Pericarditis Ultrasound 40

Dr. Smith's ECG Blog

APRIL 8, 2015

Check : [vitals, SOB, Chest Pain, Ultrasound] If the patient has Abdominal Pain, Chest Pain, Dyspnea or Hypoxemia, Headache, Hypotension , then these should be considered the primary chief complaint (not syncope). Evidence of acute ischemia (may be subtle) vii. Aortic Dissection, Valvular (especially Aortic Stenosis), Tamponade.

Arrhythmia 52

Arrhythmia Outcomes Chest Pain Risk Factors 52

Dr. Smith's ECG Blog

DECEMBER 16, 2024

But it also shows a massive area of total ischemia in the LAD territory: CT shows the infarct The CT is with contrast, which increases density (which looks more white). And almost all of them could be detected by bedside ultrasound. It is not a waste of time to use bedside ultrasound to look for dissection 3.

Chest Pain 105

Chest Pain STEMI Aortic Ultrasound 105