Cardiac Ischemia ECG Workshop

Transcription

1 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

2 A Few Points To Start Advanced content

3 A Few Points To Start Advanced content Courtesy Heidi Farinholt, MD

4 A Few Points To Start Workshop Questions? Writing Handout/PDF Lectures.umem.org/SEMA Lectures will be posted for 1 month

5 A Few Points To Start Workshop Questions? Writing Handout/PDF Lectures.umem.org/SEMA Lectures will be posted for 1 month

6 Why is this important?

7 Why is this important? ACS is high-risk but high payoff! Very good outcome vs. very bad outcome

8 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

9 Why is this important? Missed ACS accounts for 20% of malpractice dollars paid out in EM > 25% of cases involve ECG misreads

10 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

11 Some basics

12 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.

13 Acute Myocardial Infarction/Ischemia ECG changes ST elevation injury pattern Q-waves infarcted tissue Develop within hours Significant Q-waves

14 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

15 ECG changes Acute Myocardial Infarction Anterior MI usually associated with LAD occlusion STE in leads V1-V6

16 ECG changes Septal MI Acute Myocardial Infarction STE limited to leads V1-V2 Anteroseptal MI STE in leads V1-V4 Anterolateral MI STE in leads V3-V6, I, and avl

17 ECG changes Inferior MI Acute Myocardial Infarction usually RCA occlusion STE in II, III, avf reciprocal changes most common in avl always consider possibility of posterior and/or right ventricular involvement

18 avr avl I III avf II

19 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

20 avr avl I III avf II

21 STE in I and avl, high lateral STEMI

22 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)

23 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]

24 Accelerated Idioventricular Rhythm (AIVR)

25 Cases

26 #1: 81 yo woman with SOB, orthopnea, and edema

27 #1: LBBB with AMI

28 Acute Myocardial Infarction Who gets acute reperfusion therapy for presumed STEMI?

29 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]

30 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]

31 New LBBB and AMI Neeland, et al. JACC 2012

32 Normal LBBB Rule of appropriate discordance (true for pacemakers also)

33 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 B A A B Courtesy Bill Brady, MD

34 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) B A B A Courtesy Bill Brady, MD

35 Concordance / Discordance QRS complex - ST segment / T wave Discordance A. Normal: < 5mm B. Potentially abnormal: > 5mm B A Courtesy Bill Brady, MD

36 Left Bundle Branch Block Diagnosis of AMI -- Sgarbossa criteria A -- Concordant ST elevation > 1 mm in any lead B -- Concordant ST depression > 1 mm in V 1, V 2, or V 3 C -- Discordant ST elevation > 5 mm (less specific) Criteria are very specific though have low sensitivity. A B C Courtesy Bill Brady, MD

37 Left Bundle Branch Block Diagnosis of AMI -- Sgarbossa criteria A -- Concordant ST elevation > 1 mm in any lead B -- Concordant ST depression > 1 mm in V 1, V 2, or V 3 C -- Discordant ST elevation > 5 mm (less specific) Criteria are very specific though have low sensitivity. A B C Courtesy Bill Brady, MD

38 #1: LBBB with AMI

39 #1: LBBB with AMI

40 Courtesy Bill Brady, MD LBBB with AMI

41 Courtesy Bill Brady, MD LBBB with AMI

42 LBBB with AMI

43 LBBB with AMI

44 LBBB with AMI

45 LBBB with AMI

46 LBBB with AMI

47 LBBB with AMI

48 LBBB with AMI Courtesy Dr. Nicolas Pineda

49 LBBB with AMI Courtesy Dr. Nicolas Pineda

50 85 yo woman with CP Courtesy Dr. Eric Klotz

51 85 yo woman with CP Courtesy Dr. Eric Klotz

52 Rapid Afib (147) and LBBB with AMI

53 Rapid Afib (147) and LBBB with AMI

54 Normal (AV Sequential) Pacemaker

55 Pacemaker with AMI

56 38 yo woman with chest pain Courtesy Jim Campagna, MD

57 Baseline ECG Courtesy Jim Campagna, MD

58 38 yo woman with chest pain Courtesy Jim Campagna, MD

59 90 yo man with CP Courtesy Nicolina Andersson, MD

60 90 yo man with CP Courtesy Nicolina Andersson, MD

61 76 yo man with decr. LOC + hypotension Courtesy Dr. Santiago Harris

62 Uncomplicated RBBB

63 RBBB with acute antero-lat MI (old inferior MI)

64 RBBB with acute anterolateral MI

65 #2: 58 yo man with CP and SOB at home, now asymp.

66 #2: Wellens Syndrome

67 Wellens Syndrome De Zwann C, Bar FW, Wellens HJJ (Am Heart J, 1982) Pattern of ECG T-wave abnormality in midprecordial leads (V2-V3, + V4) Highly specific for critical obstruction in proximal LAD High risk for extensive anterior MI, death 2 patterns

68 Wellens Syndrome V2 V3 Deep TWIs Biphasic

69 Wellens Syndrome Warnings Type 2 pattern often misdiagnosed as nonspecific T-wave pattern or normal ST changes are often absent ECG abnormality usually present in pain-free state Cardiac biomarkers often normal initially

70 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

71 Wellens Syndrome

72 Wellens Syndrome

73 Wellens Syndrome

74 Wellens Syndrome

75 24 yo man with lupus presenting with chest pain

76 4 DAYS LATER

77 49 yo man with chest pain

78 49 yo man with chest pain (recent negative stress test)

79 Baseline ECG

80

81 Pain worsening later in day....

82 Pain worsening later in day Cath (90% LAD)

83 40 yo intoxicated man with chest pain

84 Dx GERD, but worsening symtpoms serial ECGs

85 Wellens Sign

86 Sent to cath lab 95% LAD

87 48 yo man with 2/10 chest pain (#1)

88 48 yo man with 2/10 chest pain (#2)

89 100% LAD lesion, 4v CABG

90 Wellens Sign

91 Computer: Old inferior MI, PRWP, NS-Ts

92 100% LAD occlusion

93 Pain-Free Courtesy Jason Mansour, MD

94 Baseline Courtesy Jason Mansour, MD

95

96 One hour later CP returns Courtesy Jason Mansour, MD

97 Cath 90% LAD Occlusion Courtesy Jason Mansour, MD

98 58 yo man with resolved CP, cardiol/machine: NS-Ts

99 later developed stuttering CP, TN 10

100 #3: 31 yo man with atypical chest pain

101 #3: 31 yo man with atypical chest pain

102 STE, normal variant (with high voltage)

103 Wang, et al. ST-segment elevation in conditions other than acute myocardial infarction. N Engl J Med 2003;349:

104 STE, normal variant (with high voltage)

105 STE, normal variant (with high voltage)

106 STE concave upwards before drop

107 38 yo man with chest pain, 95% LAD lesion Courtesy Chuck Sheppard, MD

108 STE, normal variant (with high voltage)

109 STE, normal variant (with high voltage)

110 STE, normal variant (with high voltage)

111 STE, normal variant (with high voltage)

112 STE, normal variant (with high voltage)

113 STE, normal variant (with high voltage)

114 STE, normal variant (with high voltage)

115 STE, normal variant (with high voltage)

116 STE, normal variant (with high voltage)

117 18 yo male with chest pain after amphetamines Courtesy Katie Baugher, DO

118 Admitted, ruled-out for MI Courtesy Katie Baugher, DO

119 Admitted, ruled-out for MI

120 #4: 49 yo man with vomiting and diarrhea for 3 days

121 #4: Severe Hypokalemia

122 Severe Hypokalemia

123 Severe Hypokalemia

124 Digoxin Toxicity With Hypokalemia

125 Severe Hypokalemia (1.8)

126 Severe Hypokalemia (2.5)

127 K + = 2.0 mmol/l Courtesy Dr. Prathibha Shenoy

128 K + = 1.2 mmol/l Courtesy Dr. Osama Muhammad Ali

129 K + = 1.2 mmol/l Courtesy Dr. Osama Muhammad Ali

130 #5: 43 yo woman with chest pain and diaphoresis

131 #5: Isolated PMI

132 Anteroseptal ischemia? ST depression in anteroseptal leads Anteroseptal ischemia Posterior STEMI Miscellaneous RBBB Hypokalemia Etc.

133 Anteroseptal ischemia? ST depression in anteroseptal leads Anteroseptal ischemia Posterior STEMI Miscellaneous RBBB Hypokalemia Etc.

134 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)

135 Posterior Myocardial Infarction ECG Changes in Leads V1-V3 Septal MI STE Inverted Ts Qs develop over hours Posterior MI

136 Posterior Myocardial Infarction ECG Changes in Leads V1-V3 Septal MI STE Inverted Ts Qs develop over hours Posterior MI STD Upright Ts Tall Rs develop over hours

137 Inferior-posterior MI

138 Inferior-posterior MI (after 2 hours)

139 43 yo woman with chest pain and diaphoresis

140 Isolated PMI

141 Courtesy Bill Brady, MD Isolated PMI

142 Isolated PMI Posterior Leads

143 Isolated PMI Posterior Leads

144 Isolated PMI Posterior Leads Courtesy Bill Brady, MD

145 Anteroseptal ischemia??

146 Isolated PMI!

147 Isolated PMI Posterior Leads

148 Anteroseptal ischemia?

149 Early PLMI Posterior Leads (V3-V6)

150 Anteroseptal ischemia?

151 Early PMI

152 Computer: Possible anterior subendocardial injury

153 PMI: V1-5 wrapped around left mid-back

154 78 yo man with syncope Courtesy Dr. Amitava Mukhopadhyay

155 Case Courtesy Dr. Amitava Mukhopadhyay 15 minutes after arrival VTach

156 Case Courtesy Dr. Amitava Mukhopadhyay 15 minutes after arrival VTach Then cardiac arrest

157 Case Courtesy Dr. Amitava Mukhopadhyay Resuscitation attempts successful Went to cath lab

158 Case Courtesy Dr. Amitava Mukhopadhyay Resuscitation attempts successful Went to cath lab successful PCI 100% RCA, 50% left Cx lesions