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ST ELEVATION. Jason Mitchell, PGY2 July 15, 2010. Context. CP and ST Elevation common ED presentation Correct ECG interpretation impacts management decisions and patient outcome Certain patients with CP and ST elevation require rapid intervention via thombolysis or PCI

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ST ELEVATION

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ST ELEVATION

Jason Mitchell, PGY2

July 15, 2010


Context

  • CP and ST Elevation common ED presentation

  • Correct ECG interpretation impacts management decisions and patient outcome

  • Certain patients with CP and ST elevation require rapid intervention via thombolysis or PCI

  • Misdiagnosis potentially harmful


Context

  • 1996 ACC/AHA Class I Recommendation for Thrombolysis

  • “ST elevation greater than 0.1 mV in two or more contiguous leads.”1

1 Ryan TJ, Anderson JL, Antman EM, et al. ACC/AHA guidelines for the management of patients with acute myocardial infarction. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction). .J Am CollCardiol. 1996 Nov 1;28(5):1328-428


Context

  • Disorders with ST Elevation Meeting ACC/AHA Thrombolysis Guideline


Context

  • 2000 ACEP Qualifier

  • “ST-segment elevations greater than 0.1 mV in 2 or more contiguous leads that are not characteristic of early repolarizationor pericarditis, nor of a repolarization abnormality from LVH or BBB in patients with clinical presentation suggestive of AMI.”2

2 Critical issues in the evaluation and management of adult patients presenting with suspected acute myocardial infarction or unstable angina. Ann Emerg Med 2000;35:521-525


ST Morphology


ST Morphology

  • Concave Up vs. Concave Down


ST Morphology

  • Concave Up vs. Concave Down


ST Segment Elevation

  • Differentiating STEMI from other ST Elevation Syndromes

    • Dynamic ECG changes

    • Reciprocal Changes


ST Morphology


STEMI Territories

  • Localizations


STEMI


STEMI


STEMI


STEMI


Context

  • 2000 ACEP Qualifier

  • “ST-segment elevations greater than 0.1 mV in 2 or more contiguous leads that are not characteristic of early repolarizationor pericarditis, nor of a repolarization abnormality from LVH or BBB in patients with clinical presentation suggestive of AMI.”2

2 Critical issues in the evaluation and management of adult patients presenting with suspected acute myocardial infarction or unstable angina. Ann Emerg Med 2000;35:521-525


Early Repolarization


Early Repolarization

  • Normal variant

  • Males > Females

  • ECG Findings:

    • Diffuse, Concave up ST Elevation 2-5mm (Usually precordial)

    • Notched J-Point

    • Prominent T-Waves

    • Temporal stability


Early Repolarization

  • “Benign” Early Repolarization

    • Increased prevalence of early repolarization in idiopathic VF

      • Most pronounced with inferior J-Point elevation

    • Increased risk of cardiac death (ie – sudden arrythmia)

      • J-Point 1mm: RR 1.28, 95% CI 1.05 – 1.59

      • J-Point 2mm: RR 2.98, 95% CI 1.85 – 4.923

    • Isolated BER in limbs leads should prompt ACS investigations

3Tikkanen JT, Anttonen O, Junttila MJ, et al. Long-term outcome associated with early repolarization on electrocardiography. N Engl J Med. 2009 Dec 24;361(26):2529-37.


Pericarditis


Pericarditis

  • Diffuse ST Elevation

  • Diffuse PR Depression

  • Caveat: aVR

    • ST Depression, PR Elevation


Pericarditis

  • Stages – All 4 Present in ~50% of patients

    • I – ST Elevation, concordant T-Waves, PR Depression

    • II – ST segments return to baseline, T-Waves flatten

    • III – T-Wave inversion

    • IV – T-Wave resolution


Pericarditis

  • Differentiation from STEMI

    • Concave Up ST segments

    • ST elevation beyond contiguous leads

    • No simultaneous T-Wave inversion

    • Reciprocal changes absent

    • Serial ECGs not consistent with STEMI patterns

      • No Q-Wave development


Pericarditis vs. BER

  • Differentiation of Pericarditis from BER

    • V6 ST/T Ratio

      • Pericarditis > 0.25

      • BER < 0.25


LVH


LVH

  • Tall R waves lateral leads

  • Deep S waves anterior precordial leads

  • Concave Up ST elevation, typically V1-V3

  • LAD


LBBB


LBBB

  • Wide QRS

  • Large, positive R wave without q or s waves in I, aVL, V6

  • Notched ‘M Shaped’ R wave V5, V6

  • Normal or leftward axis

  • ST depression and T wave inversion in leftward leads

  • ST elevation and upright T waves in right precordial leads


LBBB

  • 7% of MI4

  • Significantly less likely to receive ASA

  • Increased in-hospital mortality

4 Go AS, Barron HV, Rundle AC, et al. Bundle-branch block and in-hospital mortality in acute myocardial infarction. National Registry of Myocardial Infarction. Ann Intern Med 1998 Nov 1;129(9):690-7.


LBBB

  • Sgarbossa Criteria5

    • Score ≥ 3

      • 98% specific

      • 20% sensitive6

5Sgarbossa EB, Pinski SL, Barbagelata A, et al. Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block. GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) Investigators. N Engl J Med 1996 Feb 22;334(8):481-7.

6Tabas JA, Rodriguez RM, Seligman HK, et al. Electrocardiographic criteria for detecting acute myocardial infarction in patients with left bundle branch block: a meta-analysis. Ann Emerg Med. 2008 Oct;52(4):329-336.e1.


LBBB


LBBB

  • ECG Evolution

  • Anterolateral MI

    • New S Waves in Leftward Leads

      • I, aVL, V6

  • Anteroseptal MI

    • Lateral q waves

      • I, aVL, V5-V6


RBBB?

  • Can present with ST elevation

  • No impact on initial QRS vector

    • Q waves are not changed


Conclusion

  • Evaluate ECG in relation to clinical presentation

  • ST morphology

  • Dynamic ECG changes, serial ECGs

  • Look for reciprocal changes


Practice


Practice

  • Inferior MI

    • V1 Elevation: RV Infarct

    • ST Elevation III > ST Elevation II: RCA Occlusion


Practice


Practice

  • Hyperacute Anterior MI

    • Note Mobitz II Conduction Block

      • Malfunctioning His-Pukinje system

      • Suggests anterior occlusion

      • Ie - LAD occlusion

    • Mobitz I Conduction Block

      • Malfunctioning AV node

      • Suggests ‘dominant’ coronary occlusion

      • RCA or Circumflex


Practice


Practice

  • PosteriorMI

    • Note ‘q’ waves in anterior leads


Practice


Practice

  • WPW


Practice


Practice

  • LBBB Concerning for MI


Practice


Practice

  • Anterior MI


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