st segment elevation in conditions other than acute myocardial infarction bobby dery md department...
TRANSCRIPT
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ST Segment Elevation in Conditions ST Segment Elevation in Conditions Other Than Acute Myocardial Other Than Acute Myocardial
InfarctionInfarction
Bobby Dery MDDepartment of Emergency Medicine
St. Mary’s Hospital
Grand Junction, CO
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GoalsGoals• Review several general principles of EKG interpretation.
• Cover the common causes of ST elevation other than ischemia.
• Briefly review a few of the less common, perhaps esoteric, causes of ST elevation.
• Leave you more comfortable differentiating the various causes of ST elevation.
• Avoid putting you to sleep.
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SignificanceSignificance• AMI is often represented on the EKG by ST-segment elevation.
• Reperfusion therapy has proven beneficial in these infarctions.
• The earlier the reperfusion, the greater the benefit.
• In fact, time to reperfusion is now a closely monitored measure of quality of care.
• However, AMI is not the only source of ST-segment elevation on the EKG…
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SignificanceSignificance
• J Emerg Med 1998: 171/202 (85%) ED pts. with CP and ST elevation with dx other than MI.
• Ann Emerg Med 1994: 63/123 (51%) with CP and ST elevation with dx other than MI.
• Am J Cardiol 1994: 10/93 (11%) of pts. receiving thrombolytics did not have AMI.
• Ann Emerg Med 1996: 35/609 (6%) of pts. receiving thrombolytics did not have AMI.
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Diagnosis:Diagnosis:
Lef
t Bun
dle B
ranch
B...
Ear
ly R
epola
rizat
ion
Acu
te M
yoca
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l Inf
a...
0% 0%0%
1. Left Bundle Branch Block
2. Early Repolarization
3. Acute Myocardial Infarction
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Early repol 1Early repol 1
v1 v2 v3 v4 v5 v6
Diagnosis:Diagnosis: Early ReoplarizationEarly Reoplarization
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““Early Repolarization”Early Repolarization”
• A misnomer.
• A normal variant; seen mostly in young, healthy.
• Typical Features: - 1-4mm in mid-precordial leads- greatest elevation at V4- J-point notching common- tall T waves without inversion- concave up ST segment (“smiley”)- PR depressionearly repol of atrial tissue
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Early repol againEarly repol againEarly ReoplarizationEarly Reoplarization
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Male PatternMale PatternDiagnosis:Diagnosis:
v1 v2 v3 v4 v5 v6
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J Am Coll Cardiol 2002;40:1870-76J Am Coll Cardiol 2002;40:1870-76Surawicz et alSurawicz et al
Female Male
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J Am Coll CardiolJ Am Coll CardiolMale
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The Male PatternThe Male Pattern
• So prevalent it is a normal finding, not a normal variant.
- 1960 Am J Cardiol: 6014 healthy males (USAF). 91% with 1-3 mm elevation; greatest in V2.
- 2002 J Am Coll Cardiol: 529 males. 91% with >1 mm elevation V1-V4 among 17-24 y/o.
• Incidence of ST elevation declines with age. Only 30% of men 76 years or older display this pattern.
• Elevation of 1-3 mm. Most marked in V2. Concave up.
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Male PatternMale Pattern
v1 v2 v3 v4 v5 v6
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Diagnosis:Diagnosis:
v1 v2 v3 v4 v5 v6
• • Some young men.Some young men.• • Combination of early repol and juvenile T-wave?Combination of early repol and juvenile T-wave?• “• “Very suggestive of AMI”.Very suggestive of AMI”.
Normal Variant!!Normal Variant!!
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8 m/o with juvenile T wave pattern8 m/o with juvenile T wave pattern
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Juvenile T WavesJuvenile T Waves
• The T wave vector may be directed posteriorly in young children, resulting in an inverted T wave over right precordium.
• This vector usually becomes anterior with age. By age 10 most with upright T wave axis in V1-3.
• T waves may remain inverted in a minority of adultscalled the Persistent T Wave Pattern.
• Combine this with some ST elevation from early repolarization and you get a concerning shape!
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Nl variants summaryNl variants summary
MaleMalePatternPattern
EarlyEarlyRepol.Repol.
PersistentPersistent
T waveT wavePatternPattern
Normal and normal variantsNormal and normal variants
v1 v2 v3 v4 v5 v6
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Diagnosis:Diagnosis: LBBBLBBB
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LBBBLBBB
• Understand the EKG concept of “primary” and “secondary” ST changes.
• In general, the deeper the S wave, the greater the ST segment elevation. (i.e. secondary ST change.)
• LBBB classically has deep S waves in right sided pre-cordial leads ST elevations in these leads.
• This phenomena makes diagnosing antero-septal ischemia difficult in the presence of a LBBB.
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Diagnosis:Diagnosis: LBBBLBBB
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Diagnosis:Diagnosis:
Lef
t Ven
tricu
lar H
yp...
Hyp
erka
lem
ia
Per
icar
ditis
0% 0%0%
1. Left Ventricular Hypertrophy
2. Hyperkalemia
3. Pericarditis
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Diagnosis:Diagnosis: LVHLVH
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LVHLVH
• Again we see the deeper the S wave the greater the ST elevation…similar concept as with LBBB.
• LVH is one of the most common conditions mistaken for AMI.
• Elevated ST segments with LVH tend to be in V1 and V2 only.
• Elevated ST segments with LVH tend to be concave up; in distinction to the ST segments in AMI.
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Diagnosis:Diagnosis: LVHLVH
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PericarditisPericarditisDiagnosis:Diagnosis:
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PericarditisPericarditis
• Diffuse ST elevation in pre-cordial and limb leads: it would be rare for MI to do this.
• Typically a diffuse process, which affects the atria as well PR depression = atrial current of injury.
• Notice: aVR is a contrarian! (ST ; PR)
• ST segments usually “smiley”; < 5mm of elevation.
• These EKG findings are variably present, as pericarditis has several stages.
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PericarditisPericarditisDiagnosis:Diagnosis:
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Diagnosis:Diagnosis:
Sep
tal M
yoca
rdia
l Inf..
.
Hyp
erka
lem
ia
Bru
gada
Syndro
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0% 0%0%
1. Septal Myocardial Infaction
2. Hyperkalemia
3. Brugada Syndrome
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Brugada SyndromeBrugada SyndromeDiagnosis:Diagnosis:
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• First described in 1992 by Josep and Pedro Brugada. (see AJEM 3/03)
• Believed due to a Na channel defect in epicardium, but not in endocardium of RV.
• Structurally normal heart.
• Predisposes to VT and VF. (think syncope).
• Believed to account for 40-60% of cases of idiopathic V-fib!
Brugada SyndromeBrugada SyndromeEKG
• Complete or incomplete RBBB pattern.
• ST segment elevation in V1 and V2.
• ST segment begins from top of R’ wave, is downsloping, and ends with an inverted T wave.
V1 Brugada V1 Hyper K V1 PE
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Brugada SyndromeBrugada SyndromeDiagnosis:Diagnosis:
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HyperkalemiaHyperkalemiaDiagnosis:Diagnosis:
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HyperkalemiaHyperkalemia
• Tall, symmetric, peaked T waves (K 5’s)
• QRS prolongation (K 6’s)
• Loss of P wave amplitudeThe scaffold I use to remember these changes is that they begin at the T wave and progress backwards through the
EKG complex as serum K rises.
• “Dialysible current of injury”, aka pseudo-infarction pattern
• Sine wavedeath.
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HyperkalemiaHyperkalemiaDiagnosis:Diagnosis:
v1
v2
v3
v1
v2
v3
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Anterior Septal MIAnterior Septal MIDiagnosis:Diagnosis:
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Anterior Septal MIAnterior Septal MIDiagnosis:Diagnosis:
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Inferior MIInferior MIDiagnosis:Diagnosis:
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Ventricular AneurysmVentricular AneurysmDiagnosis:Diagnosis:
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Ventricular AneurysmVentricular Aneurysm
• Complication of AMI.
• Persistent ST elevation weeks to months after extensive MI indicates ventricular aneurysm.
• Caused by fibrosis of necrotic myocardium following transmural infarction.
• Can present as HF, arrhythmia, embolus.
• Aneurysectomy.
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Summary ThoughtsSummary Thoughts
• This is an important differential, and some of the differences are subtle.
• The most common causes of ST elevation mistaken for ACS in multiple studies were: LVH, early repolarization, BBB and ventricular aneurysm.
• In developing a differential consider: shape of the ST segment, leads involved, other features of the EKG, and the general clinical picture.
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Summary Thoughts...Summary Thoughts...
• I put the diagnoses in groups to aid memorization:
1) Three Normal Variants: male pattern, early repol, juvenile T wave pattern.
2) Two Secondary ST changes: LVH, LBBB
3) Two with weird, downsloping ST: Brugada Syndrome, hyper K
4) Pericarditis: Diffuse- it’s own catagory
5) ACS and ventricular aneurysm:
6) Other: PE, cardioversion,
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CME QuizCME Quiz
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Diagnosis:Diagnosis:
0% 0%0%
1. Left Ventricular Hypertrophy
2. Early Repolarization
3. Acute Myocardial Infarction
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Diagnosis:Diagnosis:
Lef
t Ven
tricu
lar H
yp...
Hyp
erka
lem
ia
Per
icar
ditis
0% 0%0%
1. Left Ventricular Hypertrophy
2. Hyperkalemia
3. Pericarditis
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Diagnosis:Diagnosis:
Sep
tal M
yoca
rdia
l Inf..
.
Hyp
erka
lem
ia
Bru
gada
Syndro
me
0% 0%0%
1. Septal Myocardial Infaction
2. Hyperkalemia
3. Brugada Syndrome
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Suggested ReadingSuggested Reading
• Wang et al. N Engl J Med 2003, 349:22
• J Am Coll Cardio 2002;40:1870-6
• Ann Emerg Med 1994; 23:17-24
• J Emerg Med 1998;16:797-8
• Am J Emerg Med; March, 2003
• Uptodate.com
• Am J Cardiol 1960; 6:200-31
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No masNo mas
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CME QuizCME Quiz
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EKG DreamingEKG Dreaming
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ST Segment Elevation in Conditions ST Segment Elevation in Conditions Other Than Acute Myocardial Other Than Acute Myocardial
InfarctionInfarction
B. DeryColorado West Emergency PhysiciansGrand Junction, CO
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Lastly…Lastly…
DCDCCardio-Cardio-versionversion
PEPE
v1 v2 v3 v4 v5 v6
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NEJM tracingsNEJM tracings
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nejm1nejm1
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Nejm1.1Nejm1.1
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nejm2nejm2
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Nejm2.1Nejm2.1
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Nejm3Nejm3
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nejm4nejm41
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N Engl J Med 2003;349:2128-2135. Wang K et al
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