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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 deleterious

  • 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 deleterious

  • 66 year old white male

  • ST elevation MI 6 weeks ago

  • calls EMS for SOB, diaphoresis


Left ventricular aneurysm
Left Ventricular Aneurysm deleterious

  • 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 deleterious

  • 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 deleterious

  • 18 year old white male

  • chest pain, SOB


Acute pericarditis and myocarditis
Acute Pericarditis and Myocarditis deleterious

  • 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
Pericarditis/Myocarditis deleterious

  • 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 deleterious

  • 88 year old female with chest pain for 2 hours


Left bundle branch block
Left Bundle Branch Block deleterious

  • 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



Case 4
Case 4 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

  • 40 year old female

  • SOB, cough

  • fat


Pulmonary embolism
Pulmonary Embolism 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

  • 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 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

  • 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 left-sided leads ( I, aVL, V5 and V6 as well as a QS or an rS complex in the right precordial leads ( V1 and V2corpulmonale

  • 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 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

  • 45 yo male with hypertension

  • short of breath, right sided chest pain


Left ventricular hypertrophy
Left Ventricular Hypertrophy 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

  • 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 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

  • 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 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

  • 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 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

  • 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 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

  • 38 yo diabetic female, on dialysis

  • short of breath, vomiting


Hyperkalemia
Hyperkalemia 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

  • 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


Hyperkalemia1
Hyperkalemia 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

  • 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)


Hyperkalemia2
Hyperkalemia 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

  • as QRS widens, it merges with the T wave resulting in the sine wave pattern


Case 7
Case 7 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

  • 18 yo football player

  • short of breath at halftime

  • had a fight with girlfriend before becoming short of breath


Early repolarization
Early Repolarization 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

  • 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 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

  • 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 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

  • 17 yo male, syncope in the hall at school

  • no past medical history


Brugada syndrome
Brugada Syndrome 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

  • 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 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

  • 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 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 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


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