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ST ELEVATION Jason Mitchell, PGY2 July 15, 2010. Context CP and ST Elevation common ED presentation CP and ST Elevation common ED presentation Correct.

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Presentation on theme: "ST ELEVATION Jason Mitchell, PGY2 July 15, 2010. Context CP and ST Elevation common ED presentation CP and ST Elevation common ED presentation Correct."— Presentation transcript:

1 ST ELEVATION Jason Mitchell, PGY2 July 15, 2010

2 Context CP and ST Elevation common ED presentation CP and ST Elevation common ED presentation Correct ECG interpretation impacts management decisions and patient outcome Correct ECG interpretation impacts management decisions and patient outcome Certain patients with CP and ST elevation require rapid intervention via thombolysis or PCI Certain patients with CP and ST elevation require rapid intervention via thombolysis or PCI Misdiagnosis potentially harmful Misdiagnosis potentially harmful

3 Context 1996 ACC/AHA Class I Recommendation for Thrombolysis 1996 ACC/AHA Class I Recommendation for Thrombolysis “ST elevation greater than 0.1 mV in two or more contiguous leads.” 1 “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 Coll Cardiol Nov 1;28(5):

4 Context Disorders with ST Elevation Meeting ACC/AHA Thrombolysis Guideline Disorders with ST Elevation Meeting ACC/AHA Thrombolysis Guideline Acute Myocardial InfarctionEarly Repolarization Left Ventricular HypertrophyLeft Ventricular Aneurysm Left Bundle Branch BlockVentricular Paced Rhythm Hypothermia (Osborn Waves)Hyperkalemia Brugada SyndromePulmonary Embolism Acute Cerebral HemorrhageWPW

5 Context 2000 ACEP Qualifier 2000 ACEP Qualifier “ST-segment elevations greater than 0.1 mV in 2 or more contiguous leads that are not characteristic of early repolarization or pericarditis, nor of a repolarization abnormality from LVH or BBB in patients with clinical presentation suggestive of AMI.” 2 “ST-segment elevations greater than 0.1 mV in 2 or more contiguous leads that are not characteristic of early repolarization or 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:

6 ST Morphology

7 Concave Up vs. Concave Down Concave Up vs. Concave Down

8 ST Morphology Concave Up vs. Concave Down Concave Up vs. Concave Down

9 ST Segment Elevation Differentiating STEMI from other ST Elevation Syndromes Differentiating STEMI from other ST Elevation Syndromes Dynamic ECG changes Dynamic ECG changes Reciprocal Changes Reciprocal Changes

10 ST Morphology

11 STEMI Territories Localizations Localizations

12 STEMI

13 STEMI

14 STEMI

15 STEMI LocationLeadsResponsible Vessel(s) Reciprocal Change AnteriorV1 – V4 Septal: V1 – V2 LADII, III, aVF LateralI, aVL, V5, V6LAD RCA Circumflex III, aVF, V1 InferiorII, III, aVFRCA (80%) Circumflex (15%) Both (5%) aVL, I PosteriorV1 – V3 (Depression) RCA Circumflex II, III, aVF

16 Context 2000 ACEP Qualifier 2000 ACEP Qualifier “ST-segment elevations greater than 0.1 mV in 2 or more contiguous leads that are not characteristic of early repolarization or pericarditis, nor of a repolarization abnormality from LVH or BBB in patients with clinical presentation suggestive of AMI.” 2 “ST-segment elevations greater than 0.1 mV in 2 or more contiguous leads that are not characteristic of early repolarization or 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:

17 Early Repolarization

18 Normal variant Normal variant Males > Females Males > Females ECG Findings: ECG Findings: Diffuse, Concave up ST Elevation 2-5mm (Usually precordial) Diffuse, Concave up ST Elevation 2-5mm (Usually precordial) Notched J-Point Notched J-Point Prominent T-Waves Prominent T-Waves Temporal stability Temporal stability

19 Early Repolarization “Benign” Early Repolarization “Benign” Early Repolarization Increased prevalence of early repolarization in idiopathic VF Increased prevalence of early repolarization in idiopathic VF Most pronounced with inferior J-Point elevation Most pronounced with inferior J-Point elevation Increased risk of cardiac death (ie – sudden arrythmia) Increased risk of cardiac death (ie – sudden arrythmia) J-Point 1mm: RR 1.28, 95% CI 1.05 – 1.59 J-Point 1mm: RR 1.28, 95% CI 1.05 – 1.59 J-Point 2mm: RR 2.98, 95% CI 1.85 – J-Point 2mm: RR 2.98, 95% CI 1.85 – Isolated BER in limbs leads should prompt ACS investigations Isolated BER in limbs leads should prompt ACS investigations 3 Tikkanen JT, Anttonen O, Junttila MJ, et al. Long-term outcome associated with early repolarization on electrocardiography. N Engl J Med Dec 24;361(26):

20 Pericarditis

21 Pericarditis Diffuse ST Elevation Diffuse ST Elevation Diffuse PR Depression Diffuse PR Depression Caveat: aVR Caveat: aVR ST Depression, PR Elevation ST Depression, PR Elevation

22 Pericarditis Stages – All 4 Present in ~50% of patients Stages – All 4 Present in ~50% of patients I – ST Elevation, concordant T-Waves, PR Depression I – ST Elevation, concordant T-Waves, PR Depression II – ST segments return to baseline, T-Waves flatten II – ST segments return to baseline, T-Waves flatten III – T-Wave inversion III – T-Wave inversion IV – T-Wave resolution IV – T-Wave resolution

23 Pericarditis Differentiation from STEMI Differentiation from STEMI Concave Up ST segments Concave Up ST segments ST elevation beyond contiguous leads ST elevation beyond contiguous leads No simultaneous T-Wave inversion No simultaneous T-Wave inversion Reciprocal changes absent Reciprocal changes absent Serial ECGs not consistent with STEMI patterns Serial ECGs not consistent with STEMI patterns No Q-Wave development No Q-Wave development

24 Pericarditis vs. BER Differentiation of Pericarditis from BER Differentiation of Pericarditis from BER V6 ST/T Ratio V6 ST/T Ratio Pericarditis > 0.25 Pericarditis > 0.25 BER < 0.25 BER < 0.25

25 LVH

26 LVH Tall R waves lateral leads Tall R waves lateral leads Deep S waves anterior precordial leads Deep S waves anterior precordial leads Concave Up ST elevation, typically V1-V3 Concave Up ST elevation, typically V1-V3 LAD LAD

27 LBBB

28 LBBB Wide QRS Wide QRS Large, positive R wave without q or s waves in I, aVL, V6 Large, positive R wave without q or s waves in I, aVL, V6 Notched ‘M Shaped’ R wave V5, V6 Notched ‘M Shaped’ R wave V5, V6 Normal or leftward axis Normal or leftward axis ST depression and T wave inversion in leftward leads ST depression and T wave inversion in leftward leads ST elevation and upright T waves in right precordial leads ST elevation and upright T waves in right precordial leads

29 LBBB 7% of MI 4 7% of MI 4 Significantly less likely to receive ASA Significantly less likely to receive ASA Increased in-hospital mortality 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.

30 LBBB Sgarbossa Criteria 5 Sgarbossa Criteria 5 Score ≥ 3 Score ≥ 3 98% specific 98% specific 20% sensitive 6 20% sensitive 6 5 Sgarbossa 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): Tabas 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 Oct;52(4): e1. CriterionScore Concordant ST Elevation ≥ 1mm, any lead5 ST Depression ≥ 1mm, V1-V33 Discordant ST Elevation ≥ 5mm, any lead2

31 LBBB

32 LBBB ECG Evolution ECG Evolution Anterolateral MI Anterolateral MI New S Waves in Leftward Leads New S Waves in Leftward Leads I, aVL, V6 I, aVL, V6 Anteroseptal MI Anteroseptal MI Lateral q waves Lateral q waves I, aVL, V5-V6 I, aVL, V5-V6

33 RBBB? Can present with ST elevation Can present with ST elevation No impact on initial QRS vector No impact on initial QRS vector Q waves are not changed Q waves are not changed

34 Conclusion Evaluate ECG in relation to clinical presentation Evaluate ECG in relation to clinical presentation ST morphology ST morphology Dynamic ECG changes, serial ECGs Dynamic ECG changes, serial ECGs Look for reciprocal changes Look for reciprocal changes

35 Practice

36 Practice Inferior MI Inferior MI V1 Elevation: RV Infarct V1 Elevation: RV Infarct ST Elevation III > ST Elevation II: RCA Occlusion ST Elevation III > ST Elevation II: RCA Occlusion

37 Practice

38 Practice Hyperacute Anterior MI Hyperacute Anterior MI Note Mobitz II Conduction Block Note Mobitz II Conduction Block Malfunctioning His-Pukinje system Malfunctioning His-Pukinje system Suggests anterior occlusion Suggests anterior occlusion Ie - LAD occlusion Ie - LAD occlusion Mobitz I Conduction Block Mobitz I Conduction Block Malfunctioning AV node Malfunctioning AV node Suggests ‘dominant’ coronary occlusion Suggests ‘dominant’ coronary occlusion RCA or Circumflex RCA or Circumflex

39 Practice

40 Practice Posterior MI Posterior MI Note ‘q’ waves in anterior leads Note ‘q’ waves in anterior leads

41 Practice

42 Practice WPW WPW

43 Practice

44 Practice LBBB Concerning for MI LBBB Concerning for MI

45 Practice

46 Practice Anterior MI Anterior MI


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