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The Others. MK Strecker-McGraw, MD, FACEP. ACS Mimics: Non AMI Causes of ST-Segment Elevation. ST segment elevation is important EKG criterion for dx of AMI But, there are other conditions that can cause elevation of the ST segments.

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the others
The Others
  • MK Strecker-McGraw, MD, FACEP
acs mimics non ami causes of st segment elevation
ACS Mimics: Non AMI Causes of ST-Segment Elevation
  • ST segment elevation is important EKG criterion for dx of AMI
  • But, there are other conditions that can cause elevation of the ST segments
ddx st segment elevation
DDX ST Segment Elevation
  • Left ventricular hypertrophy
  • Prinzmetal angina
  • Pulmonary embolism
  • Miscellaneous causes
  • Acute Myocardial infarction
  • Acute pericarditis or myocarditis
  • Brugada syndrome
  • Cardioversion
  • Early repolarization
  • Hyperkalemia
  • LBBB
  • Left ventricular aneurysm
case 1
Case 1
  • 66 year old white male
  • ST elevation MI 6 weeks ago
  • calls EMS for SOB, diaphoresis
left ventricular aneurysm
Left Ventricular Aneurysm
  • persistence of ST-segment elevation for 4 weeks or more suggests a ventricular aneurysm
  • when no previous EKG is available, presence of a QS wave in the setting of ST segment elevation without T-wave inversion is highly suggestive of an aneurysm
  • reciprocal changes in the inferior leads are absent
Focus on HPI
  • Aneurysm should already have Q waves
  • No reciprocal changes
  • Get old EKG’s
  • Get serial EKG’s
  • Need time and biomarkers/ECHO
case 2
Case 2
  • 18 year old white male
  • chest pain, SOB
acute pericarditis and myocarditis
Acute Pericarditis and Myocarditis
  • diffuse ST-segment elevations and PR-segment depressions
  • ST segment has concave morphology except aVR, which may be depressed
  • when ST elevation in lead II is greater in magnitude the the ST elevation in lead III, acute pericarditis is the likely diagnosis
pericarditis myocarditis
  • a depressed ST segment in lead aVL associated with an elevated ST segment in lead III suggests infarction. This relationship is not present in pericarditis or early repolarization
  • in the limb leads, significant elevations > 5mm of the ST segment are uncommon with pericarditis, if present, suspect AMI
  • junction of the QRS and ST segment (J point) is clearly discernible
case 3
Case 3
  • 88 year old female with chest pain for 2 hours
left bundle branch block
Left Bundle Branch Block
  • LBBB septal depolarization is delayed and proceeds abnormally from right to left
  • generate wide and primarily monophasic complexes ORS complex > 0.12 sec
  • a QS wave in V1 and a monophasic R wave in V6
  • large negative QRS complexes in lead V1, V2 or V3 are only seen in a few entities
key morphologic findings are a wide, slurred R wave in the left-sided leads ( I, aVL, V5 and V6 as well as a QS or an rS complex in the right precordial leads ( V1 and V2
  • absence of customary q wave in lead V6 so V6 only demonstrates an initial R wave in uncomplicated LBBB
case 4
Case 4
  • 40 year old female
  • SOB, cough
  • fat
pulmonary embolism
Pulmonary Embolism
  • most common EKG dysrhythmia with PE is normal sinus, sinus tachycardia is less common
  • morphology shows ST segment depression
  • T wave inversions V1-V4 most common
  • complete or incomplete RBBB
  • S1Q3T3
  • P pulmonale ( P wave amplitude > 2.5 mm in lead II)
New T-wave inversions are very common in cases of large PEs
  • Especially common in anteroseptal leads
  • Marriott and other others:
  • Simultaneous TWIs in anteroseptal + inferior leads is HIGHLY specific for acute pulmonary hypertension (= PE)
S1Q3T3 is a sign of acute corpulmonale
  • Any cause of acute corpulmonale (PE, PTX bronchospasm, etc) can result in the S1Q3T3 finding on the EKG
  • The ECG is often abnormal in PE, but findings are not sensitive, not specific
  • Anterior T wave inversions? Consider the diagnosis of massive or sub-massive PE.
  • The ECG is a poor diagnostic tool for PE. The greatest utility of the ECG in the patient with suspected PE is ruling out other potential life-threatening diagnoses such as MI.
case 5
Case 5
  • 45 yo male with hypertension
  • short of breath, right sided chest pain
left ventricular hypertrophy
Left Ventricular Hypertrophy
  • LVH is one of the most common causes of ST segment elevation and is frequently mistaken for AMI
  • in LVH, ST segment and the T wave deviate in the opposite direction from the major QRS complex
  • ST segment elevation has a concave contour and is generally limited to leads V1-V3
left ventricular hypertrophy1
Left Ventricular Hypertrophy
  • The deeper the S wave, the greater the ST segment elevation
  • fully developed LVH commonly shows ST segment depression with T wave inversion in leads I, aVL, V5 and V6
  • ST segment depression is often minimal and has a downsloping contour (hockey stick)
left ventricular hypertrophy2
Left Ventricular Hypertrophy
  • T waves are not deep and are asymetrically inverted ( slow downward phase with fast upward wave)
  • significant and/or horizontal ST segment depressions and deep symmetric inverted T waves are atypical and should raise concern for an ischemic process
  • T wave inversions in leads other than the lateral leads suggest myocardial ischemia
left ventricular hypertrophy3
Left Ventricular Hypertrophy
  • Stand alone criteria: R > 11 in aVL
  • Sokolow criteria: S V1 + R V5 or V6 >35
  • Cornell criteria: S V3 + R aVl > 28 mm men S V3 + R aVL > 20 mm women
case 6
Case 6
  • 38 yo diabetic female, on dialysis
  • short of breath, vomiting
  • Hyperkalemia is defined as a serum K+ of > 5.5 mEq/L
  • mild hyper-K= 5.5-6.5, moderate hyperK+ =6.5-8 and severe K+> 8mEq/L
  • The ST segment elevations associated with hyperkalemia is uncommon and can be diffuse or localized
  • unlike typical plateau or upsloping ST segment elevation, hyperkalemia often displays downsloping segments
  • hyperkalemia shortens repolarization and the T waves become symmetrically tall and peaked with pointed tips
  • the base of the T wave narrows , shortening the QT interval ( k+>5.5)
  • as K+ increases the QRS widens and you can see ST elevation or depression (K+>7)
  • with further elevation you see flattening or disappearance of P waves ( K+>8 mEq/L)
  • as QRS widens, it merges with the T wave resulting in the sine wave pattern
case 7
Case 7
  • 18 yo football player
  • short of breath at halftime
  • had a fight with girlfriend before becoming short of breath
early repolarization
Early Repolarization
  • ST segment elevation in the precordial leads most commonly V2- V5
  • amplitude ranges from 1-4 mm most marked in V4 with concave upward morphology
  • notch at the J point and tall, upright T waves
  • no reciprocal changes
early repolarization1
Early Repolarization
  • can be seen in limb leads (inferior leads II, III and aVF with the elevation in II > III
  • also find reciprocal ST segment depression in aVR
  • may find a short QT interval and high QRS voltages
case 8
Case 8
  • 17 yo male, syncope in the hall at school
  • no past medical history
brugada syndrome
Brugada Syndrome
  • inherited arrhythmogenic disease characterized by a right bundle branch like pattern on the EKG
  • associated with ST segment elevation in leads V1 and V2, less commonly V3
  • ST segment is typically downsloping and followed by an inverted T wave
  • associated with high incidence of sudden death among previously healthy individuals
brugada syndrome1
Brugada Syndrome
  • believed to be responsible for 4-12% of all nonischemic SCD and for approximately 20% of SCD in patients with structurally normal hearts
  • patients are predisposed to episodes of ventricular tachycardia
brugada syndrome2
Brugada Syndrome
  • 3 patterns associated with Brugada
  • I: ST segment elevation is triangular ( coved or convex upward) and the T waves can be inverted in leads V1 to V3
  • II: Downward displacement of the ST segment lies between the two elevations of the segment in leads V1 to V2 ( concave upward) but does not reach the baseline
  • III: Downward displacement of the ST segment lies between the 2 elevations of the segment in leads V1-V3 and the middle part of the ST segment touches the baseline