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ECGs: Ischemia and Infarction. AFAMS Resident Orientation 26 March 2012. Outline. Terminology. Injury Acute MI ST elevation in 2 contiguous leads Reciprocal ST depression Ischemia ST depression, T wave inversion Infarct Q waves. EKG Stages of MI. Hyperacute T waves (A)
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ECGs: Ischemia and Infarction AFAMS Resident Orientation 26 March 2012
Terminology • Injury • Acute MI • ST elevation in 2 contiguous leads • Reciprocal ST depression • Ischemia • ST depression, T wave inversion • Infarct • Q waves
EKG Stages of MI • Hyperacute T waves (A) • ST elevation (B) • Q waves – usually within 6-12h (C) • T wave inversions (D) • ST-T wave resolution • Q waves persist European Heart Journal 2007; 28, 2985-2991
EKG Stages of MI • Hyperacute T waves
Sinus tachycardia, Inferior MI – recent, Nonspecific ST-T wave changes
Localization of MI • Anteroseptal • ST elevation in V1-V3 • Anterior • ST elevation in V2-V4 • Lateral • ST elevation in I, AVL, V5-6 • Inferior • ST elevation in II,III,AVF
47 year old male with chest pain NSR with anteroseptal myocardial infarction
65 year old male with chest tightness NSR with acute anterior myocardial infarction
62 year old female with shortness of breath and chest discomfort Sinus Tachycardia with Lateral Myocardial Infarction
45yo wm with 2 hours of SSCP that started during exertion NSR with PVC, LAD, Acute anterolateral MI
Middle age white male awoke from sleep with chest pain Sinus tachycardia, Acute Inferior MI
Right Sided ECG • Who? • Any patient with inferior ST elevation MI • Why? • Investigate infarct involvement of RV • How? • Reverse Precordial Leads • Where to Look? • ST elevation in V4R
Not all ST changes are ischemia • While ischemia and infarction are the most concerning causes of ST changes, other causes exist • Use the clinical history to help you • Recognize patterns
20 year old asymptomatic male Sinus bradycardia, Early repolarization-> Normal variant
NSR, PACs, LVH – voltage criteria, repolarizationabnormality HCM
59yo female presents to the ER with CP NSR, Acute pericarditis (Diffuse ST elevation and PR depression), and Pericardial effusion (electrical alternans)
26 year old male with syncope NSR, RBBB, Long QT-> Brugada Syndrome
Differential Diagnosis of ST elevation • STEMI • LV aneurysm • Left Ventricular Hypertrophy • Pericarditis / Myocarditis • Early Repolarization • Normal variant • Hyperkalemia • BrugadaSyndrome • ARVD
Examples of ST Elevations NEJM 2003: 349:2128-35
Conclusions • ST changes often represent ischemia, injury or infarction • Many other possible diagnoses • Use clinical information to narrow down the list • When you are unsure, call a cardiologist