ECGs in Acute Coronary Syndromes · Subtle STEMIs, STEMI equivalents and red herrings 1 16-Sep-19...
Transcript of ECGs in Acute Coronary Syndromes · Subtle STEMIs, STEMI equivalents and red herrings 1 16-Sep-19...
ECGs in Acute Coronary Syndromes
Subtle STEMIs, STEMI equivalents and red herrings
16-Sep-191
Presented by:
Dr Peter Sage, Interventional Cardiologist – South Australia
45 yo man
1 hour of chest pain
BP 160/90
Code STEMI?
16-Sep-192
Lateral STEMI
• ST elevation I, aVL
• ST depression III, aVF
Circumflex or diagonal artery
Code STEMI - YES
16-Sep-193
56 yo man
45 minutes of chest pain
BP 120/80
16-Sep-194
Infero-posterior STEMI
• 1mm ST elevation II, III, aVF
• ST depression V2-V4
Usually right coronary
Always consider Posterior MI if ST depression V2-V4
Code STEMI - YES
16-Sep-195
Infero-postero-lateral STEMI
Code STEMI - YES
16-Sep-196
60 yo man
30 minutes of chest pain
BP 170/80
Code STEMI?
16-Sep-197
De Winter ECG
• Anterior ST depression
• Peaked anterior T waves
• +/- ST elevation aVR
Occluded proximal LAD
2% of Anterior STEMIs
Code STEMI - YES
16-Sep-198
De Winter ECG
• Anterior ST depression
• Peaked anterior T waves
• +/- ST elevation aVR
Occluded proximal LAD
2% of Anterior STEMIs
Code STEMI - YES
16-Sep-199
32 yo man
3 days intermittent chest pain
Currently pain-free
BP 110/70
Code STEMI?
16-Sep-1910
Wellen’s Syndrome
• Minor J point elevation anteriorly
• Biphasic or inverted T waves V2-V4
High grade LAD stenosis
Code STEMI - NO
16-Sep-1911
85 yo woman
Dyspnoea
BP 190/90
Code STEMI?
16-Sep-1912
LV hypertrophy
• Elevated J point V1-V3
• ST depression and T inversion V4-V6, 1, aVL
• No reciprocal ST changes
Code STEMI - NO
16-Sep-1913
79 yo man
6 hours of chest pain
16-Sep-1914
RBBB only
Code STEMI - NO
16-Sep-1915
85 yo woman
1 hour of chest pain
BP 140/80
Code STEMI?
16-Sep-1916
RBBB with Anterior STEMI
QRS>120ms
RS’R pattern V1
ST elevation V2-V5
Code STEMI - YES
16-Sep-1917
RBBB with Antero-lateral STEMI
Code STEMI - YES
16-Sep-1918
64 yo man
3 hours of chest pain
BP 80/50
Code STEMI?
16-Sep-1919
RBBB with infero-posterior MI
• RBBB
• ST elevation II, III, aVF
• ST depression V2-V3
Hypotension suggests RV involvement
Code STEMI - YES
16-Sep-1920
92 yo man
Conscious collapse, confusion
BP 130/80
Code STEMI?
16-Sep-1921
LBBB only
Code STEMI - NO
16-Sep-1922
80 yo man
2 hours of chest pain
BP 110/70
Code STEMI?
16-Sep-1923
LBBB with anterior STEMI (Sgarbossacriteria)
• Gross ST elevation V2-V4
• ST elevation aVL
• ST depression II, III, aVF
Code STEMI – If feeling confident
16-Sep-1924
16-Sep-1925
75 yo man
30 minutes of chest tightness and dyspnoea
Code STEMI?
16-Sep-1926
Old Anterior MI with
LV aneurysm
• Poor R wave progression
• Minor ST elevation V2-V4
• Very small T waves compared to QRS
• No reciprocal changes
Code STEMI - NO
16-Sep-1927
60 yo man
30 minutes of chest pain and SOB
BP 105/70
Code STEMI?
16-Sep-1928
Left main or multi-vessel ischaemia
• Elevated aVR
• Widespread ST depression
Code STEMI – consideralerting interventional team, particularly if unstable
Avoid hypotension
16-Sep-1929
Left main or multi-vessel ischaemia
• Elevated aVR
• Widespread ST depression
Code STEMI – consideralerting interventional team, particularly if unstable
Avoid hypotension
16-Sep-1930
45 yo man
3 hours of chest pain
BP 130/80
Code STEMI?
16-Sep-1931
Acute pericarditis
• Widespread ST elevation
• PR segment depression
• No reciprocal ST depression
• ST depression and PR elevation in aVR only
Code STEMI - NO
16-Sep-1932
50 yo man
Unconscious collapse
Code STEMI?
16-Sep-1933
VF
Defibrillate
Code STEMI? Depends on ECG post-defib
STEMI or equivalent – YES
Otherwise – NO
16-Sep-1934
Thank you