Masqueraders of STEMI Steven M. Costa, M.D. Assistant Professor Department of Medicine Division of Cardiology Scott & White Memorial Hospital and Clinic Texas A&M University Health Science Center
Disclosures www.ecgsource.com Expert panel member
STEMI ECG diagnostic criteria Myocardial injury: ST segment elevation without Q waves Myocardial infarction: ST segment elevation with associated Q waves Significant ST elevation: New ST segment elevation at the J point (where the QRS meets the ST segment) in > 2 contiguous leads >2 mm in leads V1, V2, V3 >1 mm in other leads *The Complete Guide to ECGs, O Keefe, 2002
Lateral Leads Inferior Leads Anterior-Septal leads
Evolution of MI A. Normal B. ST Elevation with Hyperacute T-Waves C. ST Elevation D. Evolving Q-wave, Q Resolving ST elevation & T-waveT inversion E. Q-wave & T-waveT inversion F. Q-wave
Case 1 52 y/o AAM with headache, vague chest pain and elevated BP 192/102 mmhg PMH: HTN, Renal Insuff RF: HTN
ECG 1 LVH with QRS and Repolarization changes
LVH QRS - T waves discordance. (especially in the lateral leads I, avl,, V5 and V6) ST segments are downwardly concave T waves are asymmetrical.
Echo
Case 2 41 y/o hispanic male with sharp stabbing chest pain PMH: none RF: tob use
ECG 2 Early Repolarization
Early Replorization Widespread STE J-pt elevation Concavity of initial up sloping Notching or irregular J Prominent concordant T Check prior ECG
Case 3 60 y/o Caucasian male with epigastic and mid abdominal pain, mild dyspnea without chest pain. No syncope. PMH: HTN, Obesity RF: HTN, Obesity/metabolic syndrome
ECG 3 Brugada Pattern
Brugada Syndrome
Case 3b: 76 y/o female with symptomatic PAF recently started on antiarrhythmic
Presents to ED with Fatigue
Brugada Syndrome Described in 1992 -Recurrent polymorphic ventricular tachycardia -ECG- RBBB and persistent ST elevation in leads V1-V3 and no structural heart disease. May be intermittent. Can be unmasked with Na channel blocker such as procainamide and flecainide -Autosomal dominant trait. - Should be suspected in any patient with ventricular fibrillation or polymorphic ventricular tachycardia or unexplained cardiac arrest.
Case 4 64 y/o with ESRD dizziness and weakness for 5 days. PMH: CAD with prior CABG, ESRD, DM
64 y/o with ESRD present with nausea/vomiting AV junctional rhythm/tachycardia, IVCD, nonspecific type, ST and/or T wave abnormalities suggesting myocardial ischemia, ST and/or T wave abnormalities suggesting electrolyte disturbances, Hyperkalemia...
Case 6b: 32 y/o male found down Idioventricular Rhythm, ST and/or T wave abnormalities suggesting electrolyte disturbances consider Severe Hyperkalemia
Potassium ECG changes
Case 5 57 y/o male truck driver c/o chest pain and dyspnea. Outside ED Tni-5
57 y/o truck driver with dyspnea Sinus rhythm, Right axis deviation, Right ventricular hyptertrophy, Nonspecific ST and/or T wave abnormalities, Pulmonary embolus...
CT chest
ECG manifestation of PE S1Q3T3 - prominent S in lead I, Q and inverted T in lead III Right bundle branch block (RBBB), complete or incomplete, often resolving after acute phase Right shift of QRS axis shift of transition zone from V4 to V5-6 ST elevation in VI and avr Sinus tachycardia, atrial fibrillation/flutter, or rightsided PAC/PVC T wave inversion in V1-4, often a late sign. Ferrari E, et al. The ECG in pulmonary embolism. Chest. 1997;111:537-43 Anterior T wave inversions had a sensitivity of 85%, specificity of 81% for massive PE in 80 patients with suspected to have PE; this was the most common finding on ECG (68%), followed by S1Q3T3 (50%) Rodger M, et al. Diagnostic value of the electrocardiogram in suspected pulmonary embolism. Am J Cardiol. 2000; 86:807-9 In 246 consecutive patients with PE compared to controls, only tachycardia and incomplete RBBB differentiated PE from no PE.
Case 6 47 y/o Caucasian female with 2 days cough, congestion and now sharp chest pain and pressures PMH: none RF: none TnI below assay
ECG 6
Stages of Acute Pericarditis on ECG Stage I Diffuse concave-upward ST-segment elevation with concordance of T waves; ST-segment depression in avr or V1; PR-segment depression; low voltage; absence of reciprocal ST-segment changes Stage II ST segments return to baseline; T-wave flattening Stage III T-wave inversion Stage IV Gradual resolution of T-wave inversion
Case 7 83 y/o male 2 days Pacemaker placement c/o dyspnea PMH: SSS, HTN RF: Male gender, HTN Normal vitals
ECG 7
Cath