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1IMICS OF MYOCARDIAL ISCHEMIA AND INFARCTION REVISED FOR LAS VEGAS 2008
N G ld hl M D
ECG MIMICS OF MYOCARDIAL ISCHEMIA AND INFARCTION
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Nora Goldschlager, M.D.Cardiology – San Francisco General Hospital
UCSF
Disclosures: None
PITFALLS IN THE ACCURACY OFTHE ECG DIAGNOSIS OF ACUTE MI
• Nonspecific ST/T wave abnormalities• Age of Q-waves (may not be known)• Paced ventricular rhythm• Left bundle branch block• Right bundle branch block: secondary
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• Right bundle branch block: secondary ST-T abnormalities in V1-3 can mimic anterior wall MI; tall R waves in V1-2 can mimic posterior wall MI
• Nonspecific intraventricular conduction delay with repolarizationabnormalities
DIAGNOSIS OF ACUTE MI IN LBBB
• 1 mm ST segment change in same directionas terminal QRS
• More than 5 mm ST elevation in directionopposite to QRS
• Sgarbossa criteria (NEJM 1996;334:481)
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- ST-elevation > 1 mm in lead withconcordant QRS complex 5 points
- ST-depression > 1 mm in leadsV1, V2 or V3 3 points
- ST-elevation > 5 mm in lead withdiscordant QRS complex 2 points
2IMICS OF MYOCARDIAL ISCHEMIA AND INFARCTION REVISED FOR LAS VEGAS 2008
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Same patient, baseline ECG obtained 6 months earlier
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3IMICS OF MYOCARDIAL ISCHEMIA AND INFARCTION REVISED FOR LAS VEGAS 2008
PITFALLS IN THE ECGDIAGNOSIS OF ACUTE MI: MI MIMICS - 1
• Early repolarization• Electrolyte disorders
HyperkalemiaHypokalemia
• Inflammatory conditionsPericarditis
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Pericarditis(PR depression, scooped ST segments, J point elevation)Myocarditis
• Conduction system disordersFascicle blocks
Anterior qV2-3, 1, aVL
Poor R progressionPosterior q II, III, aVF
PITFALLS IN THE ECGDIAGNOSIS OF ACUTE MI: MI MIMICS - 2
• Accessory pathways: - ventricular pre-excitation• Cardiac conditions
LVH, RVHHCM
• ArrhythmiasWid QRS t h di
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Wide QRS tachycardiasEctopic atrial tachycardias with prominent
Ta wavesPaced ventricular rhythm with inapparent
pacing artifactsJunctional or ventricular tachycardias with
retrograde conduction
Atrial flutter with flutter waves pseudo ST or Brugada pattern
PITFALLS IN THE ECG DIAGNOSISOF ACUTE MI: MI MIMICS - 3
• Other
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Osborne wavesPneumothorax with mediastinal shiftDouble standardization
4IMICS OF MYOCARDIAL ISCHEMIA AND INFARCTION REVISED FOR LAS VEGAS 2008
EARLY REPOLARIZATION
• Prevalence about 1%
• Male prevalence (87% in men, 33% in women)
• Age less than 50 (OR 3.3)
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g ( )
• High prevalence in black and Asian races
• High prevalence in athletes
• Benign clinical course
• Exercise and hyperventilation normalize the pattern
EARLY REPOLARIZATION: ECG FEATURES
• J point elevation• Terminal R wave notch• Upwardly concave ST segments• PR segment depression often seen
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g p• PR interval often short• Bradycardia common• Best seen in precordial leads (usually
V2-4); unusual in limb leads• Early transition common• T waves tall and asymmetric• U waves often present (may be negative)
HYPERKALEMIA vs ANTERIOR OR INFEROPOSTERIOR WALL MI
vs BRUGADA PATTERN
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8IMICS OF MYOCARDIAL ISCHEMIA AND INFARCTION REVISED FOR LAS VEGAS 2008
Isoelectric mimicking pauses
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PR ST scoop
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10IMICS OF MYOCARDIAL ISCHEMIA AND INFARCTION REVISED FOR LAS VEGAS 2008
RETROGRADE P WAVES –PSEUDO ST DEPRESSION
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Flutter - Pseudo ST elevation
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37 y.o. O “found down”
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6 hrs. later: T° 25° 30° C
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13IMICS OF MYOCARDIAL ISCHEMIA AND INFARCTION REVISED FOR LAS VEGAS 2008
J (OSBORNE) WAVE
Results from electrical heterogeneitybetween ventricular endo- and epicardiumduring repolarization
Seen in:
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• Hypothermia• Hypercalcemia• Intracranial (subarachnoid) bleed• Brugada syndrome• Coronary vasospasm• Idiopathic VF• ? ischemia
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