ST elevation .. ECG(EKG) ECG Addiction Made by Medical Student 05-08-2014

1. ST ELEVATION
Thanh Phuong Nguyen YC (2011-2017)
CONCLUSION
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2. INTRO…
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3. CAUSE OF ST ELEVATION
• E - Electrolytes
• L – LBBB
• E – Early Repolarization
• V – Ventricular Hypertrophy
• A – Aneurysm
• T – Treatment
• I – Infection/ Injury
• O – Osbourn Waves
• N – Non Occlusive Vasospasm
• B – Brugada Syndrome08-05-2014 3HUE UNIVERSITY OF
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4. E-HYPERKALEMIA
• Classic ECG changes
Tall “peaked” T waves
Prolongation of PR Intervals
Absent P Waves
Wide QRS
Sinusoidal pattern or V-Tach/V-Fib
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6. Symmectrical T waves
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7. WHAT TO LOOK FOR
• Peaked T wave in leads with elevation. Ouch!!
• Symmetrical Up and Down strokes
• Often wide >120ms
• ST depression in orther leads
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8. L-LEFT BUNDLE BRANCH BLOCK
• What is normal for LBBB?
• Wide complex
• ST elevation
• Look for appropriate discordance (<5mm)
** Think Sgarbossa criteria
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12. Sgarbossa Criteria
STST ElevationElevation ≥ 1 mm and≥ 1 mm and
concordantconcordant with QRSwith QRS
complexcomplex
Score 5 pointsScore 5 points
Odds Ratio (OR) 25.2Odds Ratio (OR) 25.2
ST DepressionST Depression ≥ 1 mm in≥ 1 mm in
V1, V2, V3V1, V2, V3
Score 3 pointsScore 3 points
OR 6.0OR 6.0
STST ElevationElevation ≥ 5 mm and≥ 5 mm and
discordantdiscordant with QRSwith QRS
complexcomplex
Score 2 pointsScore 2 points
OR 4.3OR 4.3
Odds Ratio: a measure of the degree of association; for example, the odds of exposure among the cases compared
with the odds of exposure among the controls (www.cefpas.it/ebm/tools/glossary.htm)08-05-2014 12HUE UNIVERSITY OF
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13. STST ElevationElevation ≥ 1 mm and≥ 1 mm and concordantconcordant with QRSwith QRS
complexcomplex
ST DepressionST Depression ≥ 1 mm in V1, V2, V3≥ 1 mm in V1, V2, V3
STST ElevationElevation ≥ 5 mm and≥ 5 mm and discordantdiscordant with QRSwith QRS
complexcomplex
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14. • A total score of 3 or more suggests that
the patient is likely experiencing an AMI
based on the ECG crtieria
• With a score less than 3, the ECG
diagnosis is less certain requiring
additional evaluation
• Chan TC, Brady WJ, Harrigan RA et al. ECG in
Emergency Medicine and Acute Care. 1st ed.
Pennsylvania: Elsevier Mosby; 2005.
Sgarbossa Criteria
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15. E-EARLY REPOLARIZATION
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16. What to look for
• Notched J point in V3
• Concave upward ST segment
• Usually in V2-V5
• PR depression
• Usually less than 2mm elevation
• Not as peaked as hyperkalemic T waves, more rounded
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18. Notching or slurring
of J point
Concave
STE
Benign Early Repolarization
Large amplitude
T wave
PR depression
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19. • ECG characteristics:
1. STE <2 mm
2. Concavity of initial portion of the ST segment
3. Notching or slurring of the terminal QRS
complex
4. Symmetrical, concordant T wave of large
amplitude
5. Widespread or diffuse distribution of STE
o Does not demonstrate territorial distribution
1. Relative temporal stability
Benign Early Repolarization
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20. V-VENTRICULAR HYPERTROPHY
• Many different scoring method
• The most commonly used are S-L criteria
• ST depression & T wave inversion in the
left-side leads: “strain” pattern
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21. ECG Diagnostic Criteria for LVH
SensitivitySensitivity SpecificitySpecificity
Sokolow-Lyon IndexSokolow-Lyon Index
SV1 + (RV5 or RV6)>35mmSV1 + (RV5 or RV6)>35mm
2222 100100
Cornell Voltage CriteriaCornell Voltage Criteria
SV3+RaVL>28 mm (men), 20mm(women)SV3+RaVL>28 mm (men), 20mm(women)
4242 9696
R1 + SIII>25 mmR1 + SIII>25 mm 1111 100100
R in aVL> 11mmR in aVL> 11mm 1111 100100
Other Criteria include Romhilt and Estes Point Score
System
Chan TC, Brady WJ, Harrigan RA et al. ECG in EmergencyChan TC, Brady WJ, Harrigan RA et al. ECG in Emergency
Medicine and Acute Care. 1st ed. Pennsylvania: Elsevier Mosby;Medicine and Acute Care. 1st ed. Pennsylvania: Elsevier Mosby;
2005.2005.
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22. Left Ventricular Hypertrophy
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23. • The initial upsloping of the elevated ST
segment is frequently concave in LVH as
opposed to the more likely flat/convex ST
segment elevation in ACS
• The T wave is usually asymmetrical in
LVHas opposed to the symmetrical T
wave seen in coronary ischemia
ECG Changes of Left Ventricular
Hypertrophy vs AMI
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24. A-Aneurysm
• Extremely difficult to pick out!!!!
• Old MI mistake
• Look for RBBB with persistent ST elevation
• Deep Q waves
• Look at T/QRS ratio: Amplitude of T wave/the depth of
the S wave
high -> Acute MI
low -> LVA
*If there is one lead in V1-V4 with a T/QRS ratio>0.36 then
MI likely
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25. T-Treatment
• Not much to say here..take a breather..It
only get harder!!!!..
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26. INFECTION-INJURY
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27. Pericarditis
• ST elevation is present in all leads except
in aVR, DIII, V1
• ST depression in aVR
• PR depression
• No Reciprocal changes
• Have to look at the entire ECG
• Must rely on good patient interview, assessment
& history
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30. Acute Pericarditis – Four Classical
Stages
• First described by
Spodick et al
• Stage I
– first few days  2
weeks
– STE, PR depression
• Stage II
– last days  weeks
– Normalization of STE
• Stage III
– after 2-3 weeks, lasts
several weeks
– T wave inversion
• Stage IV
– lasts up to several
months
– gradual resolution of
T wave changes
Chan TC, Brady WJ, Pollack M. Electrocardiographic manifestations: acuteChan TC, Brady WJ, Pollack M. Electrocardiographic manifestations: acute
myopericarditis. J Emerg Med 1999; 17 (5):865-72.myopericarditis. J Emerg Med 1999; 17 (5):865-72.
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31. Stage 1 Pericarditis
PR
Depression
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32. Stage 2 Pericarditis
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33. Stage 3 Pericarditis
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34. • PR segment depression is usually
transient but may be the earliest and most
specific sign of acute myopericarditis
• Baljepally R, Spodick DH. PR-segment deviation
as the initial electrocardiographic response in
acute pericarditis. Am J Cardiol 1998; 81
(12):1505-6.
Pericarditis
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36. Variable Shapes Of ST Segment
Elevations in AMI
Goldberger AL. Goldberger: Clinical Electrocardiography: A Simplified
Approach. 7th ed: Mosby Elsevier; 2006.
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37. MI ST SEGMENTS
• Convex upward ST segments in 2
contigous leads
• Inappropriate concordant ST seg.
• Hyperacute T waves
Symmetrical
Rounded
BIG in relation to R wave
W I D E (# Narrow in hyperkalemia)
* Look for reciprocal changes
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39. Sgarbossa … Once again!!!
STST ElevationElevation ≥ 1 mm and≥ 1 mm and concordantconcordant with QRSwith QRS
complexcomplex
ST DepressionST Depression ≥ 1 mm in V1, V2, V3≥ 1 mm in V1, V2, V3
STST ElevationElevation ≥ 5 mm and≥ 5 mm and discordantdiscordant with QRSwith QRS
complexcomplex
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40. O-OSBORNE WAVE
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41. OSBORNE WAVE
• Are possitive deflections occuring at the
junction between the QRS and the ST
segment
• Typical of severe hypothermia
• Usually has large notch
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42. J WAVES
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43. N-NON OCCLUSIVE VASOSPASM
• Think Ischemia
• Resembling MI
• Moving on………..->
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44. BRUGADA SYNDROME
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