Dr. Smith's ECG Blog

OCTOBER 31, 2024

Here is the angiogram: Very tight stenosis in circumflex, but with TIMI-3 flow, thanks to thrombolytics. Here is the circumflex after stenting: Wide open The cardiologist called Dr. Lufkin back and said "Great call!!" Later, the first troponin I returned at 0.057 ng/mL (4th generation, not high sensitivity).

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STEMI Arrhythmia Hospital Stent 107

Dr. Smith's ECG Blog

JANUARY 25, 2024

2 years prior he had an angiogram which showed 90% proximal stenosis of the circumflex. Left main: no obvious stenosis. LAD: severe in-stent restenosis in the mid (80%) and distal (90%) segment and diffuse disease distally. D1: severe (90%) de-novo stenosis in the mid to distal segment. LCX: non-dominant.

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Chest Pain Stenosis Stent Stents 75

Dr. S. Venkatesan MD

FEBRUARY 25, 2024

It means either a percutaneous coronary intervention with a stent or CABG. Reference : Apart from the heavily quoted classics of COURAGE, BARI-2D, ISCHEMIA, ORBITA 1 etc. You may be. But I am not.You need to undergo some re-vascularisation procedure. What do you mean by that Doctor ? No we can’t.

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Plaque Chest Pain Stent Stents 59

EMS 12-Lead

APRIL 21, 2022

There is appreciable STE aVR with near-global STD that appropriately maximizes in Leads II and V5, and thus suggesting a circumstance of generic, diffusely populated, circumferential subendocardial ischemia versus occlusive coronary thrombus. [1] STEMI was activated and the patient went to Cath on arrival.

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Ischemia Myocardial Infarction Blog Coronary Angiogram 52

Dr. Smith's ECG Blog

JUNE 19, 2023

The patient has also developed sinus bradycardia, which may result from right coronary artery ischemia to the SA node. Angiogram showed a culprit lesion of 100% stenosis to the right coronary artery and 100% stenosis of the right posterior descending artery, both with TIMI 0 flow.

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Chest Pain STEMI Cardiogenic Shock Ischemia 52

Dr. Smith's ECG Blog

SEPTEMBER 4, 2016

Down-up T-waves in inferior leads are almost always reciprocal to ischemia in the territory underlying aVL. This is not normal and is a tip off that there is posterior ischemia accompanying the ischemia in aVL. It was opened and stented. Data from stress testing proves that the ST depression of ischemia does not localize.

Ischemia 52

Ischemia Chest Pain Stenosis STEMI 52

Dr. Smith's ECG Blog

SEPTEMBER 5, 2023

I would expect TIMI-3 flow (normal flow, no persistent ischemia) with a culprit in the RCA (or possibly Circumflex). I would expect that a stent would be placed. The angiogram showed an open artery with 95% stenosis and thrombosis and it was stented. What would I expect the angiogram to show?

Chest Pain 87

Chest Pain STEMI Stent Stents 87

Dr. Smith's ECG Blog

JANUARY 28, 2023

Prior ECG available on file from 2 months before: We do not know the clinical events happening during this ECG, but there is borderline tachycardia, PVCs, and likely some evidence of subendocardial ischemia with small STDs maximal in V5-6/II, slight reciprocal STE in aVR. Normal RV, no valve stenosis or regurgitation.

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STEMI Chest Pain Stent Stents 52

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.

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Chest Pain STEMI Echocardiogram Stent 109

Dr. Smith's ECG Blog

AUGUST 9, 2019

Post by Smith and Meyers Sam Ghali ( [link] ) just asked me (Smith): "Steve, do left main coronary artery *occlusions* (actual ones with transmural ischemia) have ST Depression or ST Elevation in aVR?" That said, complete LM occlusion would be expected to have subepicardial ischemia (STE) in these myocardial territories: STE vector 1.

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Myocardial Infarction Ischemia STEMI Cardiogenic Shock 52

EMS 12-Lead

MAY 20, 2022

There is ventricular hypertrophy in the absence of abnormal loading conditions, such as aortic stenosis, or hypertension, for example – of which the most common variant is Asymmetric Septal Hypertrophy. There is LBBB-like morphology with persistent patterns of subendocardial ischemia.

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Cardiomyopathy Ischemia STEMI Coronary Angiogram 52

Dr. Smith's ECG Blog

MARCH 9, 2013

A stent was placed. For those who depend on echocardiogram to confirm the ECG findings of ischemia, this should be sobering. In this case, the duration of ischemia was so brief that there was no such evolution, and there was near-normalization. Ischemia may be so brief that Wellens' waves do not evolve 3. Lessons: 1.

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Myocardial Infarction Chest Pain Ischemia Angina 52

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

The patient’s angiogram should have been expedited, but the EKG change was not recognized as recurrence of transmural ischemia. The red arrow points to a 90% stenosis in the proximal segment of the LAD. RAO Caudal View Post PCI This is the RAO Caudal view after thrombectomy and stent placement.

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Chest Pain Blog Hospital Tachycardia 111

Dr. Smith's ECG Blog

JANUARY 28, 2018

More Smith comment: it is true that ST depression (STD) due to subendocardial ischemia does not localize [it is usually diffuse ST depression, in multiple leads and not reciprocal to ST elevation in an opposite territory], this ST depression is different! Both were stented. Notice how useful serial ECGs are! mm ST depression in aVL.

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Pericarditis Ischemia STEMI Chest Pain 52

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. The cath lab was activated: Result: Thrombotic 95% stenosis at the ostium of a small LPL2 with 70% stenosis at the LPL2/LPDA bifurcation in the distal/AV groove Cx Tubular 70% stenosis in the mid-circumflex. (In

Chest Pain 52

Chest Pain Pericarditis Stent Stents 52

Dr. Smith's ECG Blog

SEPTEMBER 16, 2015

A middle-aged male with h/o CAD and stents presented with typical chest pressure. The so-called "ST Elevation" is really the end of the QRS of Right Bundle Branch block. --Is there likely to be fixed coronary stenosis that led to demand ischemia during pneumonia? --Was This is a very common misread.

STEMI 52

STEMI Chest Pain Cardiac Arrest Stent 52

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.

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Chest Pain Coronary Artery Bypass Graft Pericarditis Blog 52

Dr. Smith's ECG Blog

JULY 16, 2022

This middle aged male with h/o GERD but also h/o stents presented to the ED with chest pain. A 3rd troponin returned before the angiogram was done and was 2956 ng/L Here is the angiogram description: The distal RCA has mild diffuse disease and bifurcates to give a large RPDA which is without significant stenosis.

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Chest Pain Bradycardia Blog Critical Care 52

Dr. Smith's ECG Blog

AUGUST 28, 2020

This is ischemia until proven otherwise. Here I annotate it: This shows 100% occluded circumflex (red arrow) and a 90% stenosis of the LAD (Yellow arrow). The LAD was thought to be not thrombotic, but a chronic tight stenosis. I learned that the patient is on Sotalol for control of PVCs. This explains the long QT.

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Cardiogenic Shock Chest Pain Ischemia Stenosis 52

Dr. Anish Koka

MAY 16, 2023

Marked differences can be seen in the prevalence of coronary artery stenosis at autopsy by age and gender. In 30-39 year old women the rate of coronary stenosis at autopsy was 5/1,545 (0.3%) while 60-69 year old men had a prevalence of 12%, almost 40 times higher. The results of this dataset by age and gender follow. This happens.

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Chest Pain Coronary Artery Disease Cancer Heart Attack 52

Dr. Smith's ECG Blog

MAY 8, 2023

So the patient was taken for emergent cath, showing: Culprit artery: LAD (100% stenosis, TIMI 0) requiring thrombectomy and stent. EKG shown here: LAFB with no clear signs of OMI or ischemia. Queen of Hearts interpretation: Now the cardiologist considered it "STEMI"! No labs were performed. EKG and CT head were performed.

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Chest Pain Myocardial Infarction STEMI Pacemaker 52

Dr. Smith's ECG Blog

NOVEMBER 3, 2017

Angiogram showed a critical LAD thrombotic stenosis. The patient went to cath and had a distal LAD 99% stenosis with thrombus and TIMI-2 flow. After many hours, the decided that it was appropriate to do an angiogram and they found a distal LAD occlusion which was opened and stented. He underwent CABG. Male in early 40's with 1.5

Chest Pain 52

Chest Pain STEMI Bradycardia Stenosis 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. He was taken to the cath lab and underwent emergent intervention: Thrombotic stenosis of the proximal RCA (95% with evidence of plaque rupture) is the culprit for the patient's inferoposterior STEMI. He was successfully stented.

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Bradycardia Cardiogenic Shock STEMI Ischemia 52