ST Elevation Is Not Always STEMI

Does ST Elevation Always Mean
Myocard Infark ?
Hauda El Rasyid
Sub bagian aritmia

Bagian kardiovaskular FK UNAND/ RSUP Dr. M.Djamil
Padang
diagnosis banding ST elevasi
• AMI
• Normal (male pattern)
• early repolarisation
• ST elevation of normal varian
• LVH
• LBBB
• Acute pericarditis
• hiperkalemia
• brugada syndrome
• pulmonary embolism
• prinzmetal angina
• cardioversion
2
What is J point ?
• junction between end QRS complex and the beginning
of the ST segment.
• ST elevations or depressions 0.06 seconds after the J-
point
• “J-waves” or “J-point elevation” or Early repolarization
(ER), is an electrocardiographic abnormality consistent
with elevation of the junction between the end of the
QRS complex and the beginning of the ST segment in 2
contiguous leads
• Miyazaki S, Shah A, Haissaguere M. Early repolarization syndrome: a new electrical disorder
associated with sudden cardiac death. Circ J. 2010;74:2039-44.
• Kyuhyun Wang, M.D., Richard W. Asinger, M.D., and Henry J.L. Marriott, M.D. ST-Segment
Elevation in Conditions Other Than Acute Myocardial Infarction. N Engl J Med 2003;
349:2128-2135
use of the term J point.
1) J onset (Jo) should denote the onset of a

notch;
2) J peak (Jp) should denote the peak of a notch
or onset of a slur; and
3) J termination (Jt) should denote the end of a
notch or slur.
Macfarlane P, Antzelevitch C, Haissaguerre M, HV. H, Potse M, RaphaelRosso, et al. The Early

Repolarization Pattern. Am Coll Cardiol. 2015;66:470-7
Miyazaki S, Shah A, Haissaguere M. Early repolarization syndrome: a new electrical disorder
associated with sudden cardiac death. Circ J. 2010;74:2039-44.
ST Segment Changes: Identifying MI Mimics
Variation to ST – Segment Elevation
Kyuhyun Wang, M.D., Richard W. Asinger, M.D., and Henry J.L. Marriott, M.D. ST-Segment
Elevation in Conditions Other Than Acute Myocardial Infarction. N Engl J Med 2003;349:2128-35
How to measured ST segment Elevation ?

9
ST-Segment Elevation in Conditions Other
Than Acute Myocardial Infarction
• majority men: ST elevation of ≥1 mm
precordial leads, it is a normal finding, not a
normal variant, and is designated as a male
pattern;
• ST elevation < 1 mm is designated as a female
pattern.
• black men, ST segment is elevated 1 to 4 mm
in the midprecordial leads as a normal variant.
This pattern is commonly referred to as early
repolarization
ST Elevation in MI
measured at the J point, in two contiguous leads
≥0.25 mV in men < 40 years
≥0.2 mV in men > 40 years
≥0.15 mV in women
in leads V2–V3 and/or
≥0.1 mV in other leads (in the absence of LVH
or LBBB)
Thygesen K, Alpert JS, White HD. Universal definition of myocardial infarction. Eur Heart J 2007; 28:2525–2538.
• acute infarction diagnose in LBBB: problematic, if
concordant →specific for AMI
• LBBB: QRS mostly negative in V1 to V3
• ST-segment elevation from an anteroseptal

infarction cannot be manifested as a concordant
ST-segment shift
• At times, replacement of the secondary
concave ST segment with a convex ST segment
may indicatean associated anteroseptal infarct
• Another criterion that has been proposed for
recognizing an associated anteroseptal infarct
is ST-segment elevation of 5 mm or more
• ST segment is elevated diffusely, rarely in AMI
• PR segment is depressed, and such depression
is the atrial counterpart of ST-segment
elevation
• prominent ST-segment elevation of acute
myocarditis can simulate AMI
• Hyperkalemia as a cause of ST-segment
elevation is well recognized
• Other electrocardiographic features of
hyperkalemia that are often, but not always,
present are widened QRS complexes; tall,
pointed, and tented T waves; and low-
amplitude or no P waves
• complete or incomplete RBBB is present.
• high take off ST segment mimics the pattern of RBBB,
but the wide S waves in leads I, aVL, and V6 that are
typically seen in RBBB are missing.
• ST elevation is primarily limited to leads V1 and V2
and can have a saddleback shape, but in typical cases
the ST segment begins from the top of the R' wave, is
downsloping, and ends with an inverted T wave
•ST elevation: continuously or intermittently
•Sodium-channel blockers such as ajmaline,
flecainide, procainamide, and cocaine can
unmask or induce this electrocardiographic
pattern
• Asian populations (58%)
Type of Brugada Syndrome
– Type I: ST – segment elevation is triangular
and T waves may be inverted in V1 – V3
– Type II: downward displacement of ST –
segment (does not reach baseline)
– Type III: middle part of ST segment touches
baseline
Yuka Mizusawa, MD; Arthur A.M. Wilde, MD, PhD. Brugada Syndrome. Circ Arrhythm
Electrophysiol. 2012;5:606-616.
Yuka Mizusawa, MD; Arthur A.M. Wilde, MD, PhD. Brugada Syndrome. Circ Arrhythm
Electrophysiol. 2012;5:606-616.
– T-wave inversion in the right precordial leads;
– simultaneous T-wave inversion
– ST segment elevation, or both in the anteroseptal
and inferior leads;
– an S1Q3T3 pattern;
– complete or incomplete right bundle-branch block;
– sinus tachycardia
• The ST segment can be elevated transiently
after direct-current countershock to the
precordium
• Van Gelder et al. reported that 23 of 146
patients with atrial fibrillation or flutter (16
percent) had ST-segment elevation of 5 mm or
more after undergoing transthoracic
cardioversion
• The ST segment normalized within a mean of
1.5 minutes (range, 10 seconds to 3 minutes)
• When an epicardial artery is completely
“pinched off” as a result of spasm, the ST
segment becomes elevated in the leads facing
the affected area, reflecting transmural
ischemia  Prinzmetal’s Angina
• The spasm is usually brief and the ST segment
returns to normal, with no resultant
myocardial damage
• The “early repolarization” pattern is usually found 1%
to 5% of the population.
• Most commonly found in young, athletic, black males
• In the past, early repolarization pattern of NISTE was
considered a benign pattern
• The typical pattern appears as no S wave in V3; 1-4
mm concave elevation of the ST-segment in leads V2-
V5 (most prominent in V3) and sometimes the
inferior leads; and notching of the downstroke of the
R waves (“J” wave), most distinct in lead V5 and V6
Klatsky AL, Oehm R, Cooper RA, Udaltsova N, Armstrong MA.The early repolarization normal
variant electrocardiogram: correlates and consequences. Am J Med. 2003 Aug 15; 115(3):171-7
Klatsky AL, Oehm R, Cooper RA, Udaltsova N, Armstrong MA.The early repolarization normal
variant electrocardiogram: correlates and consequences. Am J Med. 2003 Aug 15; 115(3):171-7
• LBBB typically causes marked ST changes, making it difficult
to recognize STEMI when the LBBB pattern is present.
• New or presumably new LBBB was regarded in the past as an
STEMI equivalent
• Only 1% to 9% of patients suspected of an acute myocardial
infarction have LBBB (new or old) on their ECG
• Criteria for recognizing STEMI in patients with LBBB were
published by Sgarbossa and colleagues:
(1) STE more than 0.1 MV that is concordant with the vector of
the QRS complex;
(2) ST depression of more than 0.1 mV in lead V1, V2, or V3;
(3) STE of more than 0.5 mV that is directed opposite to the QRS
direction
Alok Deshpande and Yochai Birnbaum. ST-segment elevation: Distinguishing ST elevation
myocardial infarction from ST elevation secondary to nonischemic etiologies. World J Cardiol.
2014 Oct 26; 6(10): 1067–1079
Alok Deshpande and Yochai Birnbaum. ST-segment elevation: Distinguishing ST elevation
myocardial infarction from ST elevation secondary to nonischemic etiologies. World J Cardiol.
2014 Oct 26; 6(10): 1067–1079
Conditions mimicking acute ST-segment
elevation myocardial infarction
• A 2.3% incidence of conditions mimicking STEMI was

found in patients referred for primary PCI. A high
clinical suspicion of conditions mimicking STEMI
remains necessary
Y.L. Gu, T. Svilaas, I.C.C. van der Horst, and F. Zijlstra. Conditions mimicking acute ST-segment
elevation myocardial infarction in patients referred for primary percutaneous coronary
intervention. Neth Heart J. 2008 Oct; 16(10): 325–331.
Y.L. Gu, T. Svilaas, I.C.C. van der
Horst, and F. Zijlstra. Conditions
mimicking acute ST-segment
elevation myocardial infarction
in patients referred for primary
percutaneous coronary
intervention. Neth Heart J.
2008 Oct; 16(10): 325–331.
Conclusion
 important to understand the normal ECG and its
variant
 ECG should be consistence with clinical condition
 ST elevation is not always means STEMI
33
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ST Elevation Is Not Always STEMI

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ST Elevation Is Not Always STEMI

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Does ST Elevation Always Mean

Sub bagian aritmia

1) J onset (Jo) should denote the onset of a

Macfarlane P, Antzelevitch C, Haissaguerre M, HV. H, Potse M, RaphaelRosso, et al. The Early

Variation to ST – Segment Elevation

Macfarlane P, Antzelevitch C, Haissaguerre M, HV. H, Potse M, RaphaelRosso, et al. The Early

• LBBB: QRS mostly negative in V1 to V3

• ST-segment elevation from an anteroseptal

• A 2.3% incidence of conditions mimicking STEMI was

 ECG should be consistence with clinical condition

 ST elevation is not always means STEMI

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