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ST ELEVATION

ST ELEVATION. Jason Mitchell, PGY2 July 15, 2010. Context. CP and ST Elevation common ED presentation Correct ECG interpretation impacts management decisions and patient outcome Certain patients with CP and ST elevation require rapid intervention via thombolysis or PCI

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ST ELEVATION

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  1. ST ELEVATION Jason Mitchell, PGY2 July 15, 2010

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

  3. Context • 1996 ACC/AHA Class I Recommendation for Thrombolysis • “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 CollCardiol. 1996 Nov 1;28(5):1328-428

  4. Context • Disorders with ST Elevation Meeting ACC/AHA Thrombolysis Guideline

  5. Context • 2000 ACEP Qualifier • “ST-segment elevations greater than 0.1 mV in 2 or more contiguous leads that are not characteristic of early repolarizationor 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;35:521-525

  6. ST Morphology

  7. ST Morphology • Concave Up vs. Concave Down

  8. ST Morphology • Concave Up vs. Concave Down

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

  10. ST Morphology

  11. STEMI Territories • Localizations

  12. STEMI

  13. STEMI

  14. STEMI

  15. STEMI

  16. Context • 2000 ACEP Qualifier • “ST-segment elevations greater than 0.1 mV in 2 or more contiguous leads that are not characteristic of early repolarizationor 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;35:521-525

  17. Early Repolarization

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

  19. Early Repolarization • “Benign” Early Repolarization • Increased prevalence of early repolarization in idiopathic VF • Most pronounced with inferior J-Point elevation • Increased risk of cardiac death (ie – sudden arrythmia) • J-Point 1mm: RR 1.28, 95% CI 1.05 – 1.59 • J-Point 2mm: RR 2.98, 95% CI 1.85 – 4.923 • Isolated BER in limbs leads should prompt ACS investigations 3Tikkanen JT, Anttonen O, Junttila MJ, et al. Long-term outcome associated with early repolarization on electrocardiography. N Engl J Med. 2009 Dec 24;361(26):2529-37.

  20. Pericarditis

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

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

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

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

  25. LVH

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

  27. LBBB

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

  29. LBBB • 7% of MI4 • Significantly less likely to receive ASA • 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 Criteria5 • Score ≥ 3 • 98% specific • 20% sensitive6 5Sgarbossa 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):481-7. 6Tabas 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. 2008 Oct;52(4):329-336.e1.

  31. LBBB

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

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

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

  35. Practice

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

  37. Practice

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

  39. Practice

  40. Practice • PosteriorMI • Note ‘q’ waves in anterior leads

  41. Practice

  42. Practice • WPW

  43. Practice

  44. Practice • LBBB Concerning for MI

  45. Practice

  46. Practice • Anterior MI

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