ST CHANGES Robert Fields, DO

NONSPECIFIC ST-T WAVE CHANGES Electrolyte abnormalities Post-cardiac surgical state Anemia Fever Acidosis or alkalosis Catecholamines Drugs Acute abdominal process Endocrine abnormalities Metabolic changes Cerebrovascular accidents Diseases such as myocarditis, pericarditis, cardiomyopathy, pulmonary emboli, infections, amyloidosis, systemic diseases, lung diseases

ST-T WAVE CHANGES ASSOCIATED WITH SPECIFIC DISEASE STATES — Specific patterns of ST-T wave changes may be seen in association with various disease states. Specific patterns of ST-T wave changes may be seen in association with various disease states. Ischemia Myocardial Injury V1-V2 — anteroseptal V3-V4 — anteroapical V5-V6 — anterolateral 1, aVL — lateral 2, 3, aVF — inferior Pericarditis LVH Intraventricular conduction Delays (RBBB, LBBB)’ Aneurysm Persistent Juvenile t-wave pattern Shortened QT intervals, ie Early Repolarization

Presented by Robert Fields, DO ST-Segment Elevation in Conditions Other Than Acute Myocardial Infarction Kyuhyun Wang, M.D., Richard W. Asinger, M.D., and Henry J.L. Marriott, M.D. Presented by Robert Fields, DO Director/Chairman of Saint Joseph Mercy Livingston Emergency Department

Normal/Schnormal The elevation was most common and marked in lead V2. Tracing 1 in Figure 1 is an example of normal ST-segment elevation. In a study of 6014 healthy men in the U.S. Air Force who were 16 to 58 years old, 91 percent had ST-segment elevation of 1 to 3 mm in one or more precordial leads.6 The elevation was most common and marked in lead V2. The prevalence of ST-segment elevation of at least 1 mm in one or more of leads V1 through V4 was 93 percent in the men who were 17 to 24 years old.7

Now the fun begins…. Electrocardiograms Showing Normal ST-Segment Elevation and Normal Variants Figure 1. Electrocardiograms Showing Normal ST-Segment Elevation and Normal Variants. Tracing 1 shows normal ST-segment elevation. Approximately 90 percent of healthy young men have ST-segment elevation of 1 to 3 mm in one or more precordial leads. The ST segment is concave. Tracing 2 shows the early-repolarization pattern, with a notch at the J point in V4. The ST segment is concave, and the T waves are relatively tall. Tracing 3 shows a normal variant that is characterized by terminal T-wave inversion. The QT interval tends to be short, and the ST segment is coved. Wang K et al. N Engl J Med 2003;349:2128-2135

Normal Variant In some healthy young people, especially in black men, the ST segment is elevated by 1 to 4 mm in the midprecordial leads as a normal variant. This pattern is commonly referred to as early repolarization,8 even though clinical studies have failed to demonstrate an earlier-than-normal onset of ventricular recovery.9

Now the fun begins…. Electrocardiograms Showing Normal ST-Segment Elevation and Normal Variants Figure 1. Electrocardiograms Showing Normal ST-Segment Elevation and Normal Variants. Tracing 1 shows normal ST-segment elevation. Approximately 90 percent of healthy young men have ST-segment elevation of 1 to 3 mm in one or more precordial leads. The ST segment is concave. Tracing 2 shows the early-repolarization pattern, with a notch at the J point in V4. The ST segment is concave, and the T waves are relatively tall. Tracing 3 shows a normal variant that is characterized by terminal T-wave inversion. The QT interval tends to be short, and the ST segment is coved. Wang K et al. N Engl J Med 2003;349:2128-2135

Early Repolarization “Early repolarization is characterized by…elevation at point where depol meets repol This is known as J – point elevation The elevation is carried into ST segment Tracing 2 in Figure 1 is an example of the early-repolarization pattern. In most instances of early repolarization, the ST-segment elevation is most marked in V4, there is a notch at the J point (the junction between the QRS complex and the ST segment), and the ST segment is concave. The T waves are tall and are not inverted

Now the fun begins…. Electrocardiograms Showing Normal ST-Segment Elevation and Normal Variants Figure 1. Electrocardiograms Showing Normal ST-Segment Elevation and Normal Variants. Tracing 1 shows normal ST-segment elevation. Approximately 90 percent of healthy young men have ST-segment elevation of 1 to 3 mm in one or more precordial leads. The ST segment is concave. Tracing 2 shows the early-repolarization pattern, with a notch at the J point in V4. The ST segment is concave, and the T waves are relatively tall. Tracing 3 shows a normal variant that is characterized by terminal T-wave inversion. The QT interval tends to be short, and the ST segment is coved. Wang K et al. N Engl J Med 2003;349:2128-2135

What do you think about tracing three? Difficult situation on this one particularly if this person is having chest pain… Combination of Early Repolarization and persistent juvenile t-wave pattern

Any major group excluded…yes In contrast, about 20 percent of normal electrocardiograms from women had ST-segment elevation of 1 mm or more, and this prevalence remained unchanged regardless of the women's ages.

So how would you describe the first one… Dr Z dictating on patient…..the 12 lead EKG reveals… “A male pattern variant with associated non-pathological ST elevation of 1mm in lead V2” Since the majority of men have ST elevation of 1 mm or more in precordial leads, it is a normal finding, not a normal variant, and is designated as a male pattern

What do you think about “early repolarization” ? Benign Malignant I don’t know I don’t care (unless of course I have it…)

NEJM May 2008 Volume 358:2016-2023 May 8, 2008 Number 19 NEJM Sudden Cardiac Arrest Associated with Early Repolarization Michel Haïssaguerre, M.D., Nicolas Derval, M.D., Frederic Sacher, M.D., Laurence Jesel, M.D., Isabel Deisenhofer, M.D., Luc de Roy, M.D., Jean-Luc Pasquié, M.D., Ph.D., Akihiko Nogami, M.D., Dominique Babuty, M.D., Sinikka Yli-Mayry, M.D., Christian De Chillou, M.D., Patrice Scanu, M.D., Philippe Mabo, M.D., Seiichiro Matsuo, M.D., Vincent Probst, M.D., Ph.D., Solena Le Scouarnec, Ph.D., Pascal Defaye, M.D., Juerg Schlaepfer, M.D., Thomas Rostock, M.D., Dominique Lacroix, M.D., Dominique Lamaison, M.D., Thomas Lavergne, M.D., Yoshifusa Aizawa, M.D., Anders Englund, M.D., Frederic Anselme, M.D., Mark O'Neill, M.D., Meleze Hocini, M.D., Kang Teng Lim, M.B., B.S., Sebastien Knecht, M.D., George D. Veenhuyzen, M.D., Pierre Bordachar, M.D., Michel Chauvin, M.D., Pierre Jais, M.D., Gaelle Coureau, Ph.D., Genevieve Chene, Ph.D., George J. Klein, M.D., and Jacques Clémenty, M.D.

Tracings We Will See LVH LBBB Pericarditis Hyperkalemia AMI Brugada Syndrome

Electrocardiograms Showing ST-Segment Elevation in Various Conditions Figure 2. Electrocardiograms Showing ST-Segment Elevation in Various Conditions. Tracing 1 is from a patient with left ventricular hypertrophy, and tracing 2 is from a patient with left bundle-branch block. Tracing 3, from a patient with acute pericarditis, is the only tracing with ST-segment elevation in both precordial leads and lead II and PR-segment depression. Tracing 4 shows a pseudoinfarction pattern in a patient with hyperkalemia. The T wave in V3 is tall, narrow, pointed, and tented. Tracing 5 is from a patient with acute anteroseptal infarction. The distinctive features of tracing 6, from a patient with acute anteroseptal infarction and right bundle-branch block, include the remaining R' wave and the distinct transition between the downstroke of R' and the beginning of the ST segment. Tracing 7, from a patient with the Brugada syndrome, shows rSR' and ST-segment elevation limited to V1 and V2. The ST segment begins from the top of the R' and is downsloping. Wang K et al. N Engl J Med 2003;349:2128-2135

LVH Recall Criteria for LVH The two most important pressure overload states are systemic hypertension and aortic stenosis. The major conditions associated with left ventricular volume overload are aortic or mitral valve regurgitation and dilated cardiomyopathy.

LVH Cornell voltage criteria — These more recent criteria are based upon echocardiographic correlative studies designed to detect a left ventricular mass index >132 g/m2 in men and >109 g/m2 in women [14]. For men: S in V3 plus R in aVL >2.8 mV (28 mm) For women: S in V3 + R in aVL >2.0 mV (20 mm)

LBBB These secondary ST–T changes are shifted to the opposite direction from the major component of the QRS complex (i.e., discordant). When these changes are concordant, they are specific for acute myocardial infarction. Concordant = MI, Disconcordant = LBBB but does not exclude MI

Look at 2 and 5, similarity noted Electrocardiograms Showing ST-Segment Elevation in Various Conditions Figure 2. Electrocardiograms Showing ST-Segment Elevation in Various Conditions. Tracing 1 is from a patient with left ventricular hypertrophy, and tracing 2 is from a patient with left bundle-branch block. Tracing 3, from a patient with acute pericarditis, is the only tracing with ST-segment elevation in both precordial leads and lead II and PR-segment depression. Tracing 4 shows a pseudoinfarction pattern in a patient with hyperkalemia. The T wave in V3 is tall, narrow, pointed, and tented. Tracing 5 is from a patient with acute anteroseptal infarction. The distinctive features of tracing 6, from a patient with acute anteroseptal infarction and right bundle-branch block, include the remaining R' wave and the distinct transition between the downstroke of R' and the beginning of the ST segment. Tracing 7, from a patient with the Brugada syndrome, shows rSR' and ST-segment elevation limited to V1 and V2. The ST segment begins from the top of the R' and is downsloping. Wang K et al. N Engl J Med 2003;349:2128-2135

How about tracing three?

Look specifically at the limb lead What do you see? PR depression? ST elevation? Pericarditis

Pericarditis Diffuse pericarditis involves not only the subepicardial layer of the ventricular wall, which is responsible for the ST-segment elevation, but also the subepicardial layer of the atrial wall, which causes an atrial injury pattern.

Electrocardiograms Showing ST-Segment Elevation in Various Conditions Focus on tracing four… Electrocardiograms Showing ST-Segment Elevation in Various Conditions Figure 2. Electrocardiograms Showing ST-Segment Elevation in Various Conditions. Tracing 1 is from a patient with left ventricular hypertrophy, and tracing 2 is from a patient with left bundle-branch block. Tracing 3, from a patient with acute pericarditis, is the only tracing with ST-segment elevation in both precordial leads and lead II and PR-segment depression. Tracing 4 shows a pseudoinfarction pattern in a patient with hyperkalemia. The T wave in V3 is tall, narrow, pointed, and tented. Tracing 5 is from a patient with acute anteroseptal infarction. The distinctive features of tracing 6, from a patient with acute anteroseptal infarction and right bundle-branch block, include the remaining R' wave and the distinct transition between the downstroke of R' and the beginning of the ST segment. Tracing 7, from a patient with the Brugada syndrome, shows rSR' and ST-segment elevation limited to V1 and V2. The ST segment begins from the top of the R' and is downsloping. Wang K et al. N Engl J Med 2003;349:2128-2135

Hyperkalemia Even though the pseudoinfarction pattern of hyperkalemia is well known, the ST-segment elevation is so striking at times that one cannot help agonizing over the possibility of coexistent acute infarction. How would you know…echocardiogram? Ok how about a potassium level and treat it stat…you will see the changes immediately.

Tracings five and six…

STEMI Ok, why….

Brugada Syndrome The syndrome has been linked to mutations in the cardiac sodium-channel gene,25 Which result in a depression or a loss of the action-potential dome in the right ventricular epicardium but not in the endocardium, creating a transmural voltage gradient that is responsible for the ST-segment elevation in the right precordial leads and the genesis of ventricular fibrillation.26,27,28 The Brugada syndrome is characterized by electrocardiographic abnormalities, and diagnostic criteria have been proposed Recognition is imperative… Idiopathic ventricular fibrillation

References ST-Segment Elevation in Conditions Other Than Acute Myocardial Infarction Kyuhyun Wang, M.D., Richard W. Asinger, M.D., and Henry J.L. Marriott, M.D. Sudden Cardiac Arrest Associated with Early Repolarization Michel Haïssaguerre, M.D., Nicolas Derval, M.D., Frederic Sacher, M.D., Laurence Jesel, M.D., Isabel Deisenhofer, M.D., Luc de Roy, M.D., Jean-Luc Pasquié, M.D., Ph.D., Akihiko Nogami, M.D., Dominique Babuty, M.D., Sinikka Yli-Mayry, M.D., Christian De Chillou, M.D., Patrice Scanu, M.D., Philippe Mabo, M.D., Seiichiro Matsuo, M.D., Vincent Probst, M.D., Ph.D., Solena Le Scouarnec, Ph.D., Pascal Defaye, M.D., Juerg Schlaepfer, M.D., Thomas Rostock, M.D., Dominique Lacroix, M.D., Dominique Lamaison, M.D., Thomas Lavergne, M.D., Yoshifusa Aizawa, M.D., Anders Englund, M.D., Frederic Anselme, M.D., Mark O'Neill, M.D., Meleze Hocini, M.D., Kang Teng Lim, M.B., B.S., Sebastien Knecht, M.D., George D. Veenhuyzen, M.D., Pierre Bordachar, M.D., Michel Chauvin, M.D., Pierre Jais, M.D., Gaelle Coureau, Ph.D., Genevieve Chene, Ph.D., George J. Klein, M.D., and Jacques Clémenty, M.D. Other Resources including “uptodate.com”

Electrocardiograms from a Patient with Massive Pulmonary Embolism Who Had a Normal Coronary Angiogram (Tracing 1) and a Patient with Transient ST-Segment Elevation Immediately after Direct-Current (DC) Countershock to the Precordium (Tracing 2) Figure 3. Electrocardiograms from a Patient with Massive Pulmonary Embolism Who Had a Normal Coronary Angiogram (Tracing 1) and a Patient with Transient ST-Segment Elevation Immediately after Direct-Current (DC) Countershock to the Precordium (Tracing 2). Wang K et al. N Engl J Med 2003;349:2128-2135