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
But…

3. We all know what to do with this…
But are our tools sensitive enough to capture everyone who will benefit from acute intervention (PCI or fibrinolysis)…

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

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

7. 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

8. Another critical left main stenosis

9. A recent case - EMS EKG

10. EKG in the ED

11. 90% left main occlusion

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

13. 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

14. Acute inferior – posterior MI

15. ST-segment depression in V1-3
ST-depression
in V1-3
With flipped EKG
 ST elevation
“inverted reflection”

16. A recent case – circ stent

17. Evolving posterior MI with tall R-V2

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

20. Wellens’ warning Left anterior descending (LAD)
Associated with changes V2-4
Deeply inverted T waves
Biphasic T waves
Change from initial normal EKG
During pain-free interval
Normal enzymes

21. Wellens’ syndrome

22. Wellens’ syndrome, type 2

23. Wellens’ original description - 1982
18% of admitted unstable angina
50% on presentation
Remainder within 24 hours
If NOT revascularized  75% large anterior MI
…within weeks

24. 60-year-old man with chest pain earlier in the day

25. ECG from 1 month prior

26. Previous EKG Presentation

27. One week later…

28. Case 4. 60-yo man with chest pain

29. de Winter’s sign Persistent hyperacute T’s ST-segment depression
Proximal LAD occlusion
2% of anterior MIs
30/1532 anterior MI
de Winter NEJM 2008
Verouden Heart 2009

31. In conclusion…
Remember these STEMI equivalents

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

33. In conclusion… Critical left main occlusion Isolated posterior MI
ST-depression in V2-3
Evolving tall R in V1-2

34. In conclusion… Critical left main occlusion Isolated posterior MI
Wellens’ warning
Inverted or biphasic T waves V2-3
An impending anterior MI

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

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

37.
@STorreyMD