ECGs in Acute Coronary Syndromes

Subtle STEMIs, STEMI equivalents and red herrings

16-Sep-191

Presented by:

Dr Peter Sage, Interventional Cardiologist – South Australia

45 yo man

1 hour of chest pain

BP 160/90

Code STEMI?

16-Sep-192

Lateral STEMI

• ST elevation I, aVL

• ST depression III, aVF

Circumflex or diagonal artery

Code STEMI - YES

16-Sep-193

56 yo man

45 minutes of chest pain

BP 120/80

16-Sep-194

Infero-posterior STEMI

• 1mm ST elevation II, III, aVF

• ST depression V2-V4

Usually right coronary

Always consider Posterior MI if ST depression V2-V4

Code STEMI - YES

16-Sep-195

Infero-postero-lateral STEMI

Code STEMI - YES

16-Sep-196

60 yo man

30 minutes of chest pain

BP 170/80

Code STEMI?

16-Sep-197

De Winter ECG

• Anterior ST depression

• Peaked anterior T waves

• +/- ST elevation aVR

Occluded proximal LAD

2% of Anterior STEMIs

Code STEMI - YES

16-Sep-198

De Winter ECG

• Anterior ST depression

• Peaked anterior T waves

• +/- ST elevation aVR

Occluded proximal LAD

2% of Anterior STEMIs

Code STEMI - YES

16-Sep-199

32 yo man

3 days intermittent chest pain

Currently pain-free

BP 110/70

Code STEMI?

16-Sep-1910

Wellen’s Syndrome

• Minor J point elevation anteriorly

• Biphasic or inverted T waves V2-V4

High grade LAD stenosis

Code STEMI - NO

16-Sep-1911

85 yo woman

Dyspnoea

BP 190/90

Code STEMI?

16-Sep-1912

LV hypertrophy

• Elevated J point V1-V3

• ST depression and T inversion V4-V6, 1, aVL

• No reciprocal ST changes

Code STEMI - NO

16-Sep-1913

79 yo man

6 hours of chest pain

16-Sep-1914

RBBB only

Code STEMI - NO

16-Sep-1915

85 yo woman

1 hour of chest pain

BP 140/80

Code STEMI?

16-Sep-1916

RBBB with Anterior STEMI

QRS>120ms

RS’R pattern V1

ST elevation V2-V5

Code STEMI - YES

16-Sep-1917

RBBB with Antero-lateral STEMI

Code STEMI - YES

16-Sep-1918

64 yo man

3 hours of chest pain

BP 80/50

Code STEMI?

16-Sep-1919

RBBB with infero-posterior MI

• RBBB

• ST elevation II, III, aVF

• ST depression V2-V3

Hypotension suggests RV involvement

Code STEMI - YES

16-Sep-1920

92 yo man

Conscious collapse, confusion

BP 130/80

Code STEMI?

16-Sep-1921

LBBB only

Code STEMI - NO

16-Sep-1922

80 yo man

2 hours of chest pain

BP 110/70

Code STEMI?

16-Sep-1923

LBBB with anterior STEMI (Sgarbossacriteria)

• Gross ST elevation V2-V4

• ST elevation aVL

• ST depression II, III, aVF

Code STEMI – If feeling confident

16-Sep-1924

16-Sep-1925

75 yo man

30 minutes of chest tightness and dyspnoea

Code STEMI?

16-Sep-1926

Old Anterior MI with

LV aneurysm

• Poor R wave progression

• Minor ST elevation V2-V4

• Very small T waves compared to QRS

• No reciprocal changes

Code STEMI - NO

16-Sep-1927

60 yo man

30 minutes of chest pain and SOB

BP 105/70

Code STEMI?

16-Sep-1928

Left main or multi-vessel ischaemia

• Elevated aVR

• Widespread ST depression

Code STEMI – consideralerting interventional team, particularly if unstable

Avoid hypotension

16-Sep-1929

Left main or multi-vessel ischaemia

• Elevated aVR

• Widespread ST depression

Code STEMI – consideralerting interventional team, particularly if unstable

Avoid hypotension

16-Sep-1930

45 yo man

3 hours of chest pain

BP 130/80

Code STEMI?

16-Sep-1931

Acute pericarditis

• Widespread ST elevation

• PR segment depression

• No reciprocal ST depression

• ST depression and PR elevation in aVR only

Code STEMI - NO

16-Sep-1932

50 yo man

Unconscious collapse

Code STEMI?

16-Sep-1933

VF

Defibrillate

Code STEMI? Depends on ECG post-defib

STEMI or equivalent – YES

Otherwise – NO

16-Sep-1934

Thank you