1. STEMI Equivalents … an opportunity to save myocardium Susan P. Torrey, MD, FAAEM, FACEP Associate Professor of Emergency Medicine Tufts University School of Medicine

2. Disclosures None Nada Niente

3. We all know what to do with this…

4. STEMI Equivalents Critical left main disease Isolated posterior MI Wellens’ syndrome Persistent hyperacute T waves (de Winters)

5. Case 1. 70-yo farmer with chest pain

6. Critical Left Main Artery Disease Wellens described association with: ST-segment depression ≥ 8 leads ST-segment elevation in lead aVR Especially if ST-elevation in aVL

7. Another critical left main stenosis

8. A recent case - EMS EKG

9. EKG in the ED

10. 90% left main occlusion

11. Case 2. 48-yo man with chest pain

12. Isolated posterior wall MI Posterior MI usually with inferior MI 5% MIs - isolated posterior wall Isolated posterior wall MI ST-segment depression V1-3 As MI evolves: Upright T waves V1-3 Tall R waves V1-2

13. Acute inferior – posterior MI

14. ST-segment depression in V 1-3 ST-depression in V 1-3 With flipped EKG  ST elevation “inverted reflection”

15. A recent case – circ stent

16. Evolving posterior MI with tall R- V 2

18. Case 3. 65-yo woman with 90 mins severe substernal chest pain earlier

19. Wellens’ warning Left anterior descending (LAD) Associated with changes V 2-4 Deeply inverted T waves Biphasic T waves Change from initial normal EKG During pain-free interval Normal enzymes

20. Wellens’ syndrome

21. Wellens’ syndrome, type 2

22. Wellens’ original description - 1982 18% of admitted unstable angina If NOT revascularized  75% large anterior MI …within weeks

23. 60-year-old man with chest pain earlier in the day

24. ECG from 1 month prior

25. Previous EKG Presentation

26. One week later…

27. 4. 60-year-old man with chest pain

28. de Winter’s sign Persistent hyperacute T’s ST-segment depression Proximal LAD occlusion 2% of anterior MIs de Winter NEJM 2008

30. In conclusion… Remember these STEMI equivalents

31. In conclusion… Critical left main occlusion ST-depression ≥ 8 leads ST-elevation aVR

32. In conclusion… Critical left main occlusion Isolated posterior MI ST-depression in V 2-3 Evolving tall R in V 1-2

33. In conclusion… Critical left main occlusion Isolated posterior MI Wellens’ warning Inverted or biphasic T waves V 2-3

34. In conclusion… Critical left main occlusion Isolated posterior MI Wellens’ warning de Winter’s sign Persistent hyperacute T waves ST depression

35. ESC STEMI Guidelines Europ H J 33:2569, 2012 Specifically address: Isolated posterior infarction Left main coronary obstruction

36. Cardiol Clin 30:591-599, 2012