A Text Message in the Middle of the night. Do you give thrombolytics?
I awoke in the morning and discovered a text with this ECG that was sent 6 hours prior by a former resident:" 60 year old with classic chest pain. The cath lab is occupied for the next 90 minutes. Cards says " not a STEMI " . Thinking of giving lytics. "What do you think?What do you do?I texted back: " Sorry for delay! Was sleeping. This is OMI!! Did you give lytics? Proximal LAD. Great catch! "There is 0.5 mm of ST Elevation in V3-V6. The T-wave in V4 is far too large for the QRS. The LAD occlusion formula would be very high due to the extremely small R-wave in V...
Source: Dr. Smith's ECG Blog - July 16, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs
Would you have given thrombolytics to this NSTEMI patient?
Case submitted by Dr. James AlvaA middle aged male called EMS for chest pain. EMS arrived and confirmed that the patient was complaining of chest pain and shortness of breath.They recorded this prehospital ECG:What do you think?Normal QRS complex rhythm with hyperacute T-waves in V2-V6, I and aVL. Slight STE in V2 only, with significant STD and thus de-Winter pattern in V4-V6. Leads II and III show reciprocal depression of the ST segment (II) and T-wave (III). This is diagnostic of acute myocardial infarction of the anterolateral walls, with the most likely etiology being Occlusion of the LAD. In other words, this ECG show...
Source: Dr. Smith's ECG Blog - July 6, 2019 Category: Cardiology Authors: Pendell Source Type: blogs
Fight Aging! Newsletter, June 24th 2019
This study sought to investigate what could be learned from how these men have fared. The men were born in 1925-1928 and similar health-related data from questionnaires, physical examination, and blood samples are available for all surveys. Survival curves over various variable strata were applied to evaluate the impact of individual risk factors and combinations of risk factors on all-cause deaths. At the end of 2018, 118 (16.0%) of the men had reached 90 years of age.
Smoking in 1974 was the strongest single risk factor associated with survival, with observed percentages of men reaching 90 years being 26.3, 25.7, ...
Source: Fight Aging! - June 23, 2019 Category: Research Authors: Reason Tags: Newsletters Source Type: blogs
2 ECGs texted to me. Minimal STE in inferior leads. How important is it?
These 2 ECGs were texted to me with the words " I think acute MI, but cardiology does not. "I believed these to be 2 serial ECGs:ECG 1: (later found to be time zero):Computer read: " minimal ST depression 0.025 mm "There is a small amount of STE in II, III, aVFFrom less than 0.5 mm - 0.5 mm.There is les than 0.5 mm of reciprocal ST depression in aVL, and an inverted T-waveAnd the other: (later found to be time 24 minutes):Now there is more STE and more STDOne very telling finding are the ST segments in V2-V6:ST depression has developed in V2-V6, downsloping in V4-V6.Though minimal, this is very specific adjunctive data for...
Source: Dr. Smith's ECG Blog - June 22, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs
Extracting Evidence for Causation from the Correlation Between Excess Fat Tissue and Risk of Cardiovascular Disease
Given a good enough data set, there are ways to produce evidence for causation in the observed relationships between patient characteristics and risk of age-related disease. While it is well accepted by now that being overweight does in fact cause a raised risk of all the common age-related diseases, a shorter life expectancy, and a raised lifetime medical expenditure, more data never hurts. Researchers have a good understanding of the mechanisms involved in these relationships. In particular, visceral fat tissue around the abdominal organs generates chronic inflammation, which acts to accelerate tissue decline and age-rel...
Source: Fight Aging! - June 18, 2019 Category: Research Authors: Reason Tags: Daily News Source Type: blogs
ROSC: does the ECG to rule out OMI? And why does a heart just stop beating? And what rhythm is this?
This study had afatal flaw: they did not keep track of all the Non-STEMI patients who were NOT enrolled, but instead were sent for immediate angiogram. It was done in Europe, where the guidelines suggest taking all shockable arrests emergently to the cath lab. So it is highly likely that physicians were very reluctant to enroll patients; they did not want them to be randomized to no angiogram. This strong suspicion is supported by their data:only 22 of 437 (5.0%) patients in this study had OMI. What percent of shockable arrests without STE have an OMI? This large registry in Circ...
Source: Dr. Smith's ECG Blog - June 17, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs
ROSC: does the ECG rule out OMI? And why does a heart just stop beating? And what rhythm is this?
This study had afatal flaw: they did not keep track of all the Non-STEMI patients who were NOT enrolled, but instead were sent for immediate angiogram. It was done in Europe, where the guidelines suggest taking all shockable arrests emergently to the cath lab. So it is highly likely that physicians were very reluctant to enroll patients; they did not want them to be randomized to no angiogram. This strong suspicion is supported by their data:only 22 of 437 (5.0%) patients in this study had OMI.What percent of shockable arrests without STE have an OMI? This large registry in Circulatio...
Source: Dr. Smith's ECG Blog - June 17, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs
A patient with chest pain that is resolving. Computer interprets ED ECG as completely Normal.
This study, discussed on Salim Rezaie ' s fine site REBEL EM, implies you can trust the computer interpretation of " normal. " (http://rebelem.com/triage-ecgs-reducing-interruptions-busy-ed/)We recently wrote an editorial debunking this study: Litell, John M., H. Pendell Meyers, and Stephen W. Smith. 2019. “Emergency Physicians Should Be Shown All Triage ECGs, Even Those with a Computer Interpretation of ‘Normal.’”Journal of Electrocardiology 54 (March): 79 –81. https://doi.org/10.1016/j.jelectrocard.2019.03.003.What to do?Recording serial ECGs would be useful. The chest pain is resolving, so ...
Source: Dr. Smith's ECG Blog - June 8, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs
Ultrasound Case 095
Dr James Rippey Ultrasound Case 095
A 44 year old woman presents with calf pain after a long hike followed by a long flight. Her upper medial calf is particularly tender. You consider Baker's cyst, calf muscle tear and DVT the most likely differentials. (Source: Life in the Fast Lane)
Source: Life in the Fast Lane - June 4, 2019 Category: Emergency Medicine Authors: Dr James Rippey Tags: TOP 100 Ultrasound deep vein thrombosis DVT gastrocnemius Top 100 ultrasounds Vascular ultrasound Source Type: blogs
Drug eluting stent vs drug coated balloon in primary PCI
Paclitaxel coated balloon angioplasty was compared with drug eluting stent in acute ST elevation myocardial Infarction (STEMI) in the REVELATION ( REVascularization with paclitaxEL-coated balloon angioplasty versus drug-eluting stenting in acute myocardial infarcTION) Trial [1]. Drug coated balloons for angioplasty aims at reducing the potential disadvantages of stent implantation like stent thrombosis. It is thought improve the restenosis compared to plain old balloon angioplasty.
REVELATION was a single center prospective randomized trial in patients with STEMI. Those with a new culprit lesion in a native coronary arte...
Source: Cardiophile MD - May 25, 2019 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs
Ultrathin strut drug eluting stents for small vessel disease
Implantation of stents in small vessels is often avoided due to the risk of adverse events like stent thrombosis and restenosis. Ultra thin strut drug eluting stents may an option in such cases. A study published in JAMA Cardiology compared ultra thin strut stents with very thin strut stents and previous generation drug eluting stents in small vessel coronary artery disease [1]. It was a pre-specified substudy of the Comparison of Biodegradable Polymer and Durable Polymer Drug-eluting Stents in an All Comers Population (BIO-RESORT) trial. The types of stents used were ultrathin strut sirolimus eluting stents, very thin...
Source: Cardiophile MD - May 24, 2019 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Angiography and Interventions Coronary Interventions Source Type: blogs
LVH with expected repolarization abnormalities, or acute OMI?
A patient with DM presented with acute chest pain.Here was his ED ECG:There isLVH in limb leads, with a 17 mm R-wave in aVL, and deep S-wave in inferior leads.With this much voltage, one expects some repolarization abnormalities.Indeed, there is a bit of ST depression in aVL (discordant to the tall R-wave) that does not appear to be out of proportion.There is inferior ST Elevation, but the S-waves are also of high voltage.Is this an inferior STEMI? Or is the LVH with expected repolarization abnormalities? There is also some ST depression in V2. Possible posterior involvement?CommentTo me, the inferior ST E...
Source: Dr. Smith's ECG Blog - May 18, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs
Still Negative on Watchman
Many readers have contacted me to ask whether my negative viewson left atrial appendage occlusion with Watchman have changed since 2017.
The short answer is no. My views are even more negative today.
In 2016, I published an editorial on theHeart.org | Medscape Cardiology arguing that this procedure should stop. One of the rebuttals was that it was a blog post, not an academic editorial.
Months later, Andrew Foy, Gerald Naccarelli and I put the same argument into academic-speak and the influential journal Heart Rhythm published it.[1]
I have debated and presented this topic multiple times ...
Source: Dr John M - May 17, 2019 Category: Cardiology Authors: Dr John Source Type: blogs
Acute chest pain in a patient with cardiomyopathy and a paced rhythm.
A 70-something with h/o cardiomyopathy, ICD, LVH was awoken with sharp chest pain, 8/10, non-radiating. It worsened through the morning and she was eventually brought to the hospital.An ECG was recorded:What do you think?Here is one from 3 years prior:There is a paced rhythm in all 12 leads. The new ECG has new ST Elevation that meets the Smith modified Sgarbossa criteria in leads I, aVL, and V2. (ST elevation at the J-point is at least 25% of the depth of the preceding S-wave). Meeting the criteria in just one lead is very specific for OMI in paced rhythm.She was given aspirin, ticagrelor, and...
Source: Dr. Smith's ECG Blog - May 12, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs
Can you see through this paced rhythm?
Written by Pendell MeyersAn elderly female with known CAD and multiple stents, pacemaker, stroke, and COPD presented with 2 hours of midsternal, nonradiating chest pain at rest. Apparently on arrival to the ED the patient described her pain more as " crampy " abdominal pain, but also chest discomfort.Here is her initial ECG during active symptoms:What do you think?There is dual chamber paced rhythm (atrial and ventricular pacer spikes) with resulting LBBB-like morphology. There is massive excessively discordant STE in II, III, aVF, as well as V4-V6. There is reciprocal excessively discordant STD in I and aVL. Additionally,...
Source: Dr. Smith's ECG Blog - April 24, 2019 Category: Cardiology Authors: Pendell Source Type: blogs
