Approach to ST elevation in ECGs

Population: Patients presenting with chest pain and STE on ECG Aim: Approach to managing patients presenting with chest pain and STE on ECG with the aim of expediting diagnosis and treatment of AMI

Features in ECG with STE to examine 1) Magnitude of ST changes

STE greater in MI PTs Sum of ST deviations (ie elevation and depression) is greated in MI patients ST elevation: widespread STE more likely to be due to non-AMI causes, localised STE more likely to be due to aCS ST depression: not helpful in dx of ACS except in confounding ECG patterns (LVH, LBBB, VPR) thru application of the Rule of Discordance Concave upwards likely non-MI cause Convex upwards likely AMI Very specific but not sensitive, therefore used to rule in, but not rule out ACS widened or increased amplitude of QRS usually seen in BBB, VPR and LVH, making dx of ACS difficult Negative QRS complex in V1 (either QS or rS complex) Positive monophasic R waves in leads I, aVL, V5 & V6 May see QS complexes in III & aVF Broad R wave in V1 either monophasic R, biphasic rSR or qR morphologies Wide S or RS wave in V6 QS complexes in inferior leads Negative QRS in precordial leads Monophasic R wave in leads I & aVL +/- V5 & V6, usually a/w T inversion +/- QS complexes in II, III & AVF

2) Anatomical distribution of ST changes

-

DDx of STE:
1. 2. 3. 4. 5. 6. 7. 8. 9. STEMI LV aneurysm LBBB RBBB Ventricular Paced Rhythm (VPR) LVH Benign Early Repolarisation (BER) Acute Pericarditis NSIVCD

3) ST segment contour
-

4) QRS width and amplitude a) LBBB

Approach to Patient presenting with CP

Stabilise if necessary (ABC) ECG

b) RBBB

Non-diagnostic ECG Low Risk Group No change NSSTTW from old ECG Rely on clinical hx for dx High Risk Group Abnormal ECG Confounding ECG pattern Q waves LBBB ST changes VPR T wave LVH changes Dx Clinical Pathway in STE

NSR

Obvious STEMI PCI / Thrombolysis

c) VPR

T waves in Rt to mid precordial and inferior leads have convex upwards shape mimicking hyperacute T waves of early MI

Serial ECG & CE if indicated

Rule of Appropriate Discordance ( in BBB or VPR)

ST segment Leads with mainly negative QRS complexes (ie QS or rS complexes) should have STE Leads with mainly positive QRS complexes (ie large monophasic R waves) should have ST depression T wave T waves in leads with mainly negative QRS complexes have convex upward or tall vaulting shapes similar to hyperacute T waves in early MI T waves in leads with mainly positive QRS complexes are frequently inverted Loss of this normal QRS complex-T wave axes discordance imply an acute process eg AMI

1) NSR normal sinus rhythm 2) NSSTW (Non-specific ST segment/T wave abnormalities) ST elevation/depression of <1mm Blunted/flattened/biphasic T waves w/o inversion or hyperacuity Low risk of AMI but high risk of non-AMI ACS 3) Abnormal ECG ST changes, T inversion, Q waves 4) Confounding ECGs (LBBB, VPR, LVH) ability to detect ACS is limited due to the abnormal repolarisation that accompany these patterns of abnormal intraventricular conductions

d) LVH
Definition: voltage criteria V1 S wave + V5/6 R wave 35mm Poor R wave progression

V1 & V2: loss of septal R wave in Rt to mid precordial leads, usually resulting in QS pattern (ie mostly negative); usually a/w concave pattern STE and prominent T waves Leads I, aVL, V5 & V6: ST depression with downsloping ST segment; prominent R waves; assymetrical (gradual downsloping initial limb with abrupt return to baseline), biphasic or inverted T waves

Diagnostic Clinical Pathway in STE Overview

Identify chest pain patients with STE For STE in LVH, BBB & VPR (ie confounding ECG patterns) Use highly specific criterias to rule in AMI If negative, use serial ECG to f/u the patient for dynamic changes suggestive of AMI 3) For STE in uncomplicated ECGs Look for specific features to rule in AMI If negative, use serial ECG to f/u the patient for dynamic changes suggestive of AMI Use of specific criterias aims to diagnose AMI quickly based on a single ECG so as to allow for rapid diagnosis and institution of thrombolysis/PCI. 1) 2)

Digitally signed by DR WANA HLA SHWE DN: cn=DR WANA HLA SHWE, c=MY, o=UCSI University, School of Medicine, KT-Campus, Terengganu, ou=Internal Medicine Group, email=wunna. hlashwe@gmail.com Reason: This document is for UCSI University, School of Medicine students. Date: 2009.03.05 08:55:25 +08'00'

Based on Clinical Decision-making in Adult Chest Pain Patients with Electrocardiographic ST-segment Elevation: STEMI vs Non-AMI Causes of STSegment Abnormality. William J Brady, Andrew Homer. Emergency Medicine

CP patient
- Perform ECG

STE
1mm in 2 contiguous leads

1) Widened QRS complex?

No

a) VPR
Yes

b) LBBB

Sgarbossa Criteria to rule in AMI in VPR (any one of 3) STE 5mm with negative QRS STE 1mm with positive QRS ST depression 1mm with negative QRS Sgarbossa Criteria to rule in AMI in LBBB (any one of 3) STE 1mm with positive QRS ST depression 1mm in V1,2 or 3 STE 5mm with negative QRS

Aim: Predict AMI in ECGs with confounding patterns (ie LVH, BBB, VPR) Aim: Predict AMI in uncomplicated ECGs

Positive Negative

Likely MI initiate Rx Serial ECG to look for dynamic changes 0.2mm change in STE in single lead OR 0.1mm change in STE in 2 leads

Positive Negative

Likely MI No ECG evidence of MI

Sgarbossa Criteria is based on principle of appropriate discordance to look for abnormal ST segment changes It has low sensitivity & specificity, hence it is used to rule in PTs with MI in VPR/LBBB so as to allow for early initiation of Rx Does not rule out MI in VPR/LBBB, hence the need for serial ECG monitoring in PTs who do not meet Sgarbossa criteria. Aim is to look for dynamic changes that indicates ischaemic induced changes of an evolving AMI, as ST & T wave abnormalities are assumed to be temporally static in VPR/LBBB

2) Large amplitude QRS

No

LVH
SV1 + RV 5/6 35mm

STE morphology
High specificity but low sensitivity - used to rule in AMI, not to rule out AMI

Concave up

Convex up or obliquely flat

Serial ECG q4hr to look for dynamic changes 0.05mm change in STE or depression Q wave devt T inversion in 2 anatomically continuous leads Loss of ST segment concavity Suspicious for MI

Yes Yes

Positive Negative

Likely MI No ECG evidence of MI

ST segment morphology

3) STE in uncomplicated ECGs

Exclude AMI
Reciprocal ST depression (in absence of LVH, BBB, VPR)

Convex upwards or obliquely flat - specific but not sensitive, hence used to rule in AMI Positive - specific but not sensitive, hence used to rule in AMI

Suspicious for AMI

Exclude Benign Early Repolarisation Exclude Acute Pericarditis

J point notching present PR depression OR Ratio of ST height at J point in V6 to T wave apex height in V6 0.25 Ratio of sum off T wave apex heights in V1-4 to sum of QRS apex heights in V1-4 >0.22

Suspicious for AMI Suspicious for AMI

Exclude AMI

Suspicious for AMI

Serial ECG
0.05mm change in ST elevation or depression Q wave devt T inversion in 2 anatomically continuous leads Loss of ST segment concavity

Positive Negative

Likely MI No ECG evidence of MI