Post on 05-Apr-2018
Cardiac Ischemia ECG Workshop
Classic, Confusing, and Confounding Patterns
Amal Mattu, MD, NE
Professor and Vice Chair
Department of Emergency Medicine
University of Maryland School of Medicine
amalmattu@comcast.net
A Few Points To Start…
• Advanced content…
A Few Points To Start…
• Advanced content…
Courtesy Heidi Farinholt, MD
A Few Points To Start…
• Workshop
– Questions? amalmattu@comcast.net
• Writing
• Handout/PDF
– Lectures.umem.org/SEMA
– Lectures will be posted for 1 month
A Few Points To Start…
• Workshop
– Questions? amalmattu@comcast.net
• Writing
• Handout/PDF
– Lectures.umem.org/SEMA
– Lectures will be posted for 1 month
Why is this important?
Why is this important?
• ACS is high-risk but high payoff!
– Very good outcome vs. very bad outcome
Why is this important?
• ACS is high-risk but high payoff!
– Very good outcome vs. very bad outcome
• Missed ACS 25-35% mortality
– In elderly 50% 3-day mortality
Why is this important?
• Missed ACS accounts for 20% of malpractice dollars paid out in EM
• > 25% of cases involve ECG misreads
Why is this important?
• Missed ACS accounts for 20% of malpractice dollars paid out in EM
• > 25% of cases involve ECG misreads
• My experience: > 50% involve ECG misreads that are not “arguable”
Some basics…
Acute Myocardial Infarction/Ischemia
• ECG changes
– Completely normal ECG in up to 6% of acute MIs
– Subendocardial MI (NQWMI, NSTEMI) associated with ST- and T-wave abnls.
Acute Myocardial Infarction/Ischemia
• ECG changes
– ST elevation injury pattern
– Q-waves infarcted tissue
• Develop within hours
• “Significant” Q-waves
Acute Myocardial Infarction/Ischemia
• ECG changes
– ST depression ischemia or infarction
• High morbidity and mortality if untreated
– T-wave inversions ischemia
• Lower specificity and morbidity
Acute Myocardial Infarction
• ECG changes
– Anterior MI
• usually associated with LAD occlusion
• STE in leads V1-V6
Acute Myocardial Infarction
• ECG changes
– Septal MI
• STE limited to leads V1-V2
– Anteroseptal MI
• STE in leads V1-V4
– Anterolateral MI
• STE in leads V3-V6, I, and aVL
Acute Myocardial Infarction
• ECG changes
– Inferior MI
• usually RCA occlusion
• STE in II, III, aVF
• reciprocal changes most common in aVL
• always consider possibility of posterior and/or right ventricular involvement
I
II III aVF
aVL aVR
Acute Myocardial Infarction
• ECG changes
– Lateral MI
• usually left circumflex occlusion
• STE in leads I, aVL, V5-V6
• remember that leads I and aVL are both lateral contiguous leads
– even though they are not next to each other on the ECG
– isolated STE I and aVL ”high lateral MI”
I
II III aVF
aVL aVR
STE in I and aVL, “high lateral STEMI”
Acute Myocardial Infarction
• “Use of the ECG in AMI” (NEJM 2003)
– Resolution of STE marker reperfusion
– Absence of STE resolution within 90 minutes consider rescue PCI
– If reperfusion occurs, STE should resolve by at least 75% (in the lead with maximum STE)
Acute Myocardial Infarction
• “Use of the ECG in AMI” (NEJM 2003)
– T-wave inversion within 4 hours is highly specific for reperfusion
• if occurs after 4 hours, uncertain reperfusion
– [another marker that is highly specific of reperfusion AIVR]
Accelerated Idioventricular Rhythm (AIVR)
Cases
#1: 81 yo woman with SOB, orthopnea, and edema
#1: LBBB with AMI
Acute Myocardial Infarction
• Who gets acute reperfusion therapy for presumed STEMI?
Acute Myocardial Infarction
• Who gets acute reperfusion therapy for presumed STEMI?
– Concerning symptoms AND
– ECG:
• 1 mm STE in contiguous leads OR
• Posterior STEMI OR
• Presumed new LBBB OR
• LBBB with Sgarbossa criteria OR
• [Pacemaker with Sgarbossa criteria]
Acute Myocardial Infarction
• Who gets acute reperfusion therapy for presumed STEMI?
– Concerning symptoms AND
– ECG:
• 1 mm STE in contiguous leads OR
• Posterior STEMI OR
• Presumed new LBBB OR [ACC/AHA 2013]
• LBBB with Sgarbossa criteria OR
• [Pacemaker with Sgarbossa criteria]
Neeland, et al. JACC 2012
New LBBB and AMI
Normal LBBB
Rule of appropriate discordance
(true for pacemakers also)
Concordance / Discordance QRS complex - ST segment / T wave
• Discordance -- major, terminal
portion of QRS complex (“A”) &
ST segment / T wave (“B”) --
opposite sides of baseline
• Normal vs. abnormal
– “Excessive” discordant elevation
A
A
B
B
Courtesy Bill Brady, MD
Concordance / Discordance QRS complex - ST segment / T wave
• Concordance -- major,
terminal portion of QRS
complex (“A”) & ST
segment / T wave (“B”) -- same
side of baseline
• Abnormal – Concordant elevation (upper)
– Concordant depression (lower)
A
B
A
B
Courtesy Bill Brady, MD
• Discordance
A. Normal: < 5mm
B. Potentially
abnormal: > 5mm
Concordance / Discordance QRS complex - ST segment / T wave
A
B
Courtesy Bill Brady, MD
Left Bundle Branch Block Diagnosis of AMI -- Sgarbossa criteria
A B C
A -- Concordant ST elevation > 1 mm in any lead
B -- Concordant ST depression > 1 mm in V1, V2, or V3
C -- Discordant ST elevation > 5 mm (less specific)
Criteria are very specific though have low sensitivity.
Courtesy Bill Brady, MD
Left Bundle Branch Block Diagnosis of AMI -- Sgarbossa criteria
A B C
A -- Concordant ST elevation > 1 mm in any lead
B -- Concordant ST depression > 1 mm in V1, V2, or V3
C -- Discordant ST elevation > 5 mm (less specific)
Criteria are very specific though have low sensitivity.
Courtesy Bill Brady, MD
#1: LBBB with AMI
#1: LBBB with AMI
LBBB with AMI
Courtesy Bill Brady, MD
LBBB with AMI
Courtesy Bill Brady, MD
LBBB with AMI
LBBB with AMI
LBBB with AMI
LBBB with AMI
LBBB with AMI
LBBB with AMI
LBBB with AMI
Courtesy Dr. Nicolas Pineda
LBBB with AMI
Courtesy Dr. Nicolas Pineda
85 yo woman with CP Courtesy Dr. Eric Klotz
85 yo woman with CP Courtesy Dr. Eric Klotz
Rapid Afib (147) and LBBB with AMI
Rapid Afib (147) and LBBB with AMI
Normal (AV Sequential) Pacemaker
Pacemaker with AMI
38 yo woman with chest pain
Courtesy Jim Campagna, MD
Baseline ECG
Courtesy Jim Campagna, MD
38 yo woman with chest pain
Courtesy Jim Campagna, MD
90 yo man with CP
Courtesy Nicolina Andersson, MD
90 yo man with CP
Courtesy Nicolina Andersson, MD
76 yo man with decr. LOC + hypotension
Courtesy Dr. Santiago Harris
Handy Scanner for Android
Uncomplicated RBBB
RBBB with acute antero-lat MI (old inferior MI)
RBBB with acute antero-lateral MI
#2: 58 yo man with CP and SOB at home, now asymp.
#2: Wellens’ Syndrome
• De Zwann C, Bar FW, Wellens HJJ (Am Heart J, 1982)
– Pattern of ECG T-wave abnormality in mid-precordial leads (V2-V3, + V4)
– Highly specific for critical obstruction in proximal LAD
– High risk for extensive anterior MI, death
– 2 patterns…
Wellens’ Syndrome
V2 V3
Deep TWIs Biphasic
Wellens’ Syndrome
• Warnings…
– Type 2 pattern often misdiagnosed as “non-specific T-wave pattern” or “normal”
– ST changes are often absent
– ECG abnormality usually present in pain-free state
– Cardiac biomarkers often normal initially
Wellens’ Syndrome
• Warnings…
– Patients are best evaluated and managed with catheterization/PCI
• Stress testing may precipitate AMI
• Medical management usually ineffective for proximal LAD lesions
• Natural history: anterior wall MI unless early PCI
– Wellens: 75% of patients developed AMI within weeks if medically managed
Wellens’ Syndrome
Wellens’ Syndrome
Wellens’ Syndrome
Wellens’ Syndrome
Wellens’ Syndrome
24 yo man with lupus presenting with chest pain
…4 DAYS LATER
49 yo man with chest pain …
49 yo man with chest pain (recent negative stress test)
Baseline ECG
Pain worsening later in day ………………..…..
Pain worsening later in day Cath (90% LAD)
40 yo intoxicated man with chest pain
Dx GERD, but worsening symtpoms serial ECGs
Wellens’ Sign
Sent to cath lab 95% LAD
48 yo man with 2/10 chest pain (#1)
48 yo man with 2/10 chest pain (#2)
100% LAD lesion, 4v CABG
Wellens’ Sign
Computer: Old inferior MI, PRWP, NS-Ts
100% LAD occlusion
Pain-Free Courtesy Jason Mansour, MD
Baseline
Courtesy Jason Mansour, MD
One hour later CP returns…
Courtesy Jason Mansour, MD
Cath 90% LAD Occlusion
Courtesy Jason Mansour, MD
58 yo man with resolved CP, cardiol/machine: “NS-Ts”
…later developed stuttering CP, TN 10
#3: 31 yo man with atypical chest pain
#3: 31 yo man with atypical chest pain
STE, “normal variant” (with high voltage)
Wang, et al. ST-segment elevation in conditions other than acute myocardial infarction. N Engl J Med 2003;349:2128-2135.
STE, “normal variant” (with high voltage)
STE, “normal variant” (with high voltage)
STE concave upwards before drop
38 yo man with chest pain, 95% LAD lesion
Courtesy Chuck Sheppard, MD
STE, “normal variant” (with high voltage)
STE, “normal variant” (with high voltage)
STE, “normal variant” (with high voltage)
STE, “normal variant” (with high voltage)
STE, “normal variant” (with high voltage)
STE, “normal variant” (with high voltage)
STE, “normal variant” (with high voltage)
STE, “normal variant” (with high voltage)
STE, “normal variant” (with high voltage)
18 yo male with chest pain after amphetamines
Courtesy Katie Baugher, DO
Admitted, ruled-out for MI
Courtesy Katie Baugher, DO
Admitted, ruled-out for MI
#4: 49 yo man with vomiting and diarrhea for 3 days
#4: Severe Hypokalemia
Severe Hypokalemia
Severe Hypokalemia
Digoxin Toxicity With Hypokalemia
Severe Hypokalemia (1.8)
Severe Hypokalemia (2.5)
K+ = 2.0 mmol/L
Courtesy Dr. Prathibha Shenoy
K+ = 1.2 mmol/L Courtesy Dr. Osama Muhammad Ali
K+ = 1.2 mmol/L Courtesy Dr. Osama Muhammad Ali
#5: 43 yo woman with chest pain and diaphoresis
#5: Isolated PMI
Anteroseptal ischemia?
• ST depression in anteroseptal leads
– Anteroseptal ischemia
– Posterior STEMI
– Miscellaneous
• RBBB
• Hypokalemia
• Etc.
Anteroseptal ischemia?
• ST depression in anteroseptal leads
– Anteroseptal ischemia
– Posterior STEMI
– Miscellaneous
• RBBB
• Hypokalemia
• Etc.
Posterior Myocardial Infarction
• ECG changes
– Usually associated with inferior MI due to RCA or circumflex occlusion
– 4% of STEMIs are isolated PMIs
– Increased M&M compared to isolated IMI
– Mirror image of septal MI in leads V1-V3 • large R-waves (instead of Qs)
• STD (instead of STE)
• upright T-waves (instead of inversions)
Posterior Myocardial Infarction
Septal MI STE Inverted Ts
Qs develop over hours
Posterior MI
ECG Changes in Leads V1-V3
Posterior Myocardial Infarction
Septal MI STE Inverted Ts
Qs develop over hours
Posterior MI
STD Upright Ts Tall Rs develop over hours
ECG Changes in Leads V1-V3
Inferior-posterior MI
Inferior-posterior MI (after 2 hours)
43 yo woman with chest pain and diaphoresis
Isolated PMI
Isolated PMI
Courtesy Bill Brady, MD
Isolated PMI — Posterior Leads
Isolated PMI — Posterior Leads
Isolated PMI — Posterior Leads
Courtesy Bill Brady, MD
Anteroseptal ischemia…??
Isolated PMI!
Isolated PMI — Posterior Leads
Anteroseptal ischemia?
Early PLMI — Posterior Leads (V3-V6)
Anteroseptal ischemia?
Early PMI
Computer: “Possible anterior subendocardial injury”
PMI: V1-5 wrapped around left mid-back
78 yo man with syncope Courtesy Dr. Amitava Mukhopadhyay
• 15 minutes after arrival VTach
Case Courtesy Dr. Amitava Mukhopadhyay
• 15 minutes after arrival VTach
• Then cardiac arrest
Case Courtesy Dr. Amitava Mukhopadhyay
• Resuscitation attempts successful
• Went to cath lab
Case Courtesy Dr. Amitava Mukhopadhyay
• Resuscitation attempts successful
• Went to cath lab successful PCI
– 100% RCA, 50% left Cx lesions
Case Courtesy Dr. Amitava Mukhopadhyay