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The Others

The Others. MK Strecker-McGraw, MD, FACEP. ACS Mimics: Non AMI Causes of ST-Segment Elevation. ST segment elevation is important EKG criterion for dx of AMI But, there are other conditions that can cause elevation of the ST segments.

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The Others

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  1. The Others • MK Strecker-McGraw, MD, FACEP

  2. ACS Mimics: Non AMI Causes of ST-Segment Elevation • ST segment elevation is important EKG criterion for dx of AMI • But, there are other conditions that can cause elevation of the ST segments

  3. Clinical consequences of misinterpretation can be deleterious

  4. DDX ST Segment Elevation • Left ventricular hypertrophy • Prinzmetal angina • Pulmonary embolism • Miscellaneous causes • Acute Myocardial infarction • Acute pericarditis or myocarditis • Brugada syndrome • Cardioversion • Early repolarization • Hyperkalemia • LBBB • Left ventricular aneurysm

  5. Case 1 • 66 year old white male • ST elevation MI 6 weeks ago • calls EMS for SOB, diaphoresis

  6. Left Ventricular Aneurysm • persistence of ST-segment elevation for 4 weeks or more suggests a ventricular aneurysm • when no previous EKG is available, presence of a QS wave in the setting of ST segment elevation without T-wave inversion is highly suggestive of an aneurysm • reciprocal changes in the inferior leads are absent

  7. Focus on HPI • Aneurysm should already have Q waves • No reciprocal changes • Get old EKG’s • Get serial EKG’s • Need time and biomarkers/ECHO

  8. Case 2 • 18 year old white male • chest pain, SOB

  9. Acute Pericarditis and Myocarditis • diffuse ST-segment elevations and PR-segment depressions • ST segment has concave morphology except aVR, which may be depressed • when ST elevation in lead II is greater in magnitude the the ST elevation in lead III, acute pericarditis is the likely diagnosis

  10. Pericarditis/Myocarditis • a depressed ST segment in lead aVL associated with an elevated ST segment in lead III suggests infarction. This relationship is not present in pericarditis or early repolarization • in the limb leads, significant elevations > 5mm of the ST segment are uncommon with pericarditis, if present, suspect AMI • junction of the QRS and ST segment (J point) is clearly discernible

  11. Case 3 • 88 year old female with chest pain for 2 hours

  12. Left Bundle Branch Block • LBBB septal depolarization is delayed and proceeds abnormally from right to left • generate wide and primarily monophasic complexes ORS complex > 0.12 sec • a QS wave in V1 and a monophasic R wave in V6 • large negative QRS complexes in lead V1, V2 or V3 are only seen in a few entities

  13. key morphologic findings are a wide, slurred R wave in the left-sided leads ( I, aVL, V5 and V6 as well as a QS or an rS complex in the right precordial leads ( V1 and V2 • absence of customary q wave in lead V6 so V6 only demonstrates an initial R wave in uncomplicated LBBB

  14. Case 4 • 40 year old female • SOB, cough • fat

  15. Pulmonary Embolism • most common EKG dysrhythmia with PE is normal sinus, sinus tachycardia is less common • morphology shows ST segment depression • T wave inversions V1-V4 most common • complete or incomplete RBBB • S1Q3T3 • P pulmonale ( P wave amplitude > 2.5 mm in lead II)

  16. New T-wave inversions are very common in cases of large PEs • Especially common in anteroseptal leads • Marriott and other others: • Simultaneous TWIs in anteroseptal + inferior leads is HIGHLY specific for acute pulmonary hypertension (= PE)

  17. S1Q3T3 is a sign of acute corpulmonale • Any cause of acute corpulmonale (PE, PTX bronchospasm, etc) can result in the S1Q3T3 finding on the EKG • The ECG is often abnormal in PE, but findings are not sensitive, not specific • Anterior T wave inversions? Consider the diagnosis of massive or sub-massive PE. • The ECG is a poor diagnostic tool for PE. The greatest utility of the ECG in the patient with suspected PE is ruling out other potential life-threatening diagnoses such as MI.

  18. Case 5 • 45 yo male with hypertension • short of breath, right sided chest pain

  19. Left Ventricular Hypertrophy • LVH is one of the most common causes of ST segment elevation and is frequently mistaken for AMI • in LVH, ST segment and the T wave deviate in the opposite direction from the major QRS complex • ST segment elevation has a concave contour and is generally limited to leads V1-V3

  20. Left Ventricular Hypertrophy • The deeper the S wave, the greater the ST segment elevation • fully developed LVH commonly shows ST segment depression with T wave inversion in leads I, aVL, V5 and V6 • ST segment depression is often minimal and has a downsloping contour (hockey stick)

  21. Left Ventricular Hypertrophy • T waves are not deep and are asymetrically inverted ( slow downward phase with fast upward wave) • significant and/or horizontal ST segment depressions and deep symmetric inverted T waves are atypical and should raise concern for an ischemic process • T wave inversions in leads other than the lateral leads suggest myocardial ischemia

  22. Left Ventricular Hypertrophy • Stand alone criteria: R > 11 in aVL • Sokolow criteria: S V1 + R V5 or V6 >35 • Cornell criteria: S V3 + R aVl > 28 mm men S V3 + R aVL > 20 mm women

  23. Case 6 • 38 yo diabetic female, on dialysis • short of breath, vomiting

  24. Hyperkalemia • Hyperkalemia is defined as a serum K+ of > 5.5 mEq/L • mild hyper-K= 5.5-6.5, moderate hyperK+ =6.5-8 and severe K+> 8mEq/L • The ST segment elevations associated with hyperkalemia is uncommon and can be diffuse or localized • unlike typical plateau or upsloping ST segment elevation, hyperkalemia often displays downsloping segments

  25. Hyperkalemia • hyperkalemia shortens repolarization and the T waves become symmetrically tall and peaked with pointed tips • the base of the T wave narrows , shortening the QT interval ( k+>5.5) • as K+ increases the QRS widens and you can see ST elevation or depression (K+>7) • with further elevation you see flattening or disappearance of P waves ( K+>8 mEq/L)

  26. Hyperkalemia • as QRS widens, it merges with the T wave resulting in the sine wave pattern

  27. Case 7 • 18 yo football player • short of breath at halftime • had a fight with girlfriend before becoming short of breath

  28. Early Repolarization • ST segment elevation in the precordial leads most commonly V2- V5 • amplitude ranges from 1-4 mm most marked in V4 with concave upward morphology • notch at the J point and tall, upright T waves • no reciprocal changes

  29. Early Repolarization • can be seen in limb leads (inferior leads II, III and aVF with the elevation in II > III • also find reciprocal ST segment depression in aVR • may find a short QT interval and high QRS voltages

  30. Case 8 • 17 yo male, syncope in the hall at school • no past medical history

  31. Brugada Syndrome • inherited arrhythmogenic disease characterized by a right bundle branch like pattern on the EKG • associated with ST segment elevation in leads V1 and V2, less commonly V3 • ST segment is typically downsloping and followed by an inverted T wave • associated with high incidence of sudden death among previously healthy individuals

  32. Brugada Syndrome • believed to be responsible for 4-12% of all nonischemic SCD and for approximately 20% of SCD in patients with structurally normal hearts • patients are predisposed to episodes of ventricular tachycardia

  33. Brugada Syndrome • 3 patterns associated with Brugada • I: ST segment elevation is triangular ( coved or convex upward) and the T waves can be inverted in leads V1 to V3 • II: Downward displacement of the ST segment lies between the two elevations of the segment in leads V1 to V2 ( concave upward) but does not reach the baseline • III: Downward displacement of the ST segment lies between the 2 elevations of the segment in leads V1-V3 and the middle part of the ST segment touches the baseline

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