St elevation
This presentation is the property of its rightful owner.
Sponsored Links
1 / 46

ST ELEVATION PowerPoint PPT Presentation


  • 165 Views
  • Uploaded on
  • Presentation posted in: General

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

Download Presentation

ST ELEVATION

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


St elevation

ST ELEVATION

Jason Mitchell, PGY2

July 15, 2010


Context

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


Context1

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


Context2

Context

  • Disorders with ST Elevation Meeting ACC/AHA Thrombolysis Guideline


Context3

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


St morphology1

ST Morphology

  • Concave Up vs. Concave Down


St morphology2

ST Morphology

  • Concave Up vs. Concave Down


St segment elevation

ST Segment Elevation

  • Differentiating STEMI from other ST Elevation Syndromes

    • Dynamic ECG changes

    • Reciprocal Changes


St morphology3

ST Morphology


Stemi territories

STEMI Territories

  • Localizations


Stemi

STEMI


Stemi1

STEMI


Stemi2

STEMI


Stemi3

STEMI


Context4

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


Early repolarization1

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 repolarization2

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


Pericarditis1

Pericarditis

  • Diffuse ST Elevation

  • Diffuse PR Depression

  • Caveat: aVR

    • ST Depression, PR Elevation


Pericarditis2

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


Pericarditis3

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

Pericarditis vs. BER

  • Differentiation of Pericarditis from BER

    • V6 ST/T Ratio

      • Pericarditis > 0.25

      • BER < 0.25


St elevation

LVH


St elevation

LVH

  • Tall R waves lateral leads

  • Deep S waves anterior precordial leads

  • Concave Up ST elevation, typically V1-V3

  • LAD


St elevation

LBBB


St elevation

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


St elevation

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.


St elevation

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.


St elevation

LBBB


St elevation

LBBB

  • ECG Evolution

  • Anterolateral MI

    • New S Waves in Leftward Leads

      • I, aVL, V6

  • Anteroseptal MI

    • Lateral q waves

      • I, aVL, V5-V6


St elevation

RBBB?

  • Can present with ST elevation

  • No impact on initial QRS vector

    • Q waves are not changed


Conclusion

Conclusion

  • Evaluate ECG in relation to clinical presentation

  • ST morphology

  • Dynamic ECG changes, serial ECGs

  • Look for reciprocal changes


Practice

Practice


Practice1

Practice

  • Inferior MI

    • V1 Elevation: RV Infarct

    • ST Elevation III > ST Elevation II: RCA Occlusion


Practice2

Practice


Practice3

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


Practice4

Practice


Practice5

Practice

  • PosteriorMI

    • Note ‘q’ waves in anterior leads


Practice6

Practice


Practice7

Practice

  • WPW


Practice8

Practice


Practice9

Practice

  • LBBB Concerning for MI


Practice10

Practice


Practice11

Practice

  • Anterior MI


  • Login