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STEMI Equivalents - An Opportunity to Save Myocardium

This article explores STEMI equivalents, including critical left main disease, isolated posterior MI, Wellens' syndrome, and persistent hyperacute T waves. It discusses the importance of recognizing these equivalents to prevent myocardial damage.

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STEMI Equivalents - An Opportunity to Save Myocardium

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  1. STEMI Equivalents …an opportunity to save myocardium Susan P. Torrey, MD, FAAEM, FACEP Associate Professor of Emergency Medicine Tufts University School of Medicine

  2. Disclosures • None But… www.TorreyEKG.com

  3. We all know what to do with this…

  4. STEMI Equivalents • Critical left main disease • Isolated posterior MI • Wellens’ syndrome • Persistent hyperacute T waves (de Winters)

  5. Case 1. 70-yo farmer with chest pain

  6. Critical Left Main Artery Disease • Wellens described association with: • ST-segment depression ≥8 leads • ST-segment elevation in lead aVR • Especially if ST-elevation in aVL

  7. Another critical left main stenosis

  8. A recent case - EMS EKG

  9. EKG in the ED

  10. 90% left main occlusion

  11. Case 2. 48-yo man with chest pain

  12. Isolated posterior wall MI • Posterior MI usually with inferior MI • 5% MIs - isolated posterior wall • Isolated posterior wall MI • ST-segment depression V1-3 • As MI evolves: • Upright T waves V1-3 • Tall R waves V1-2

  13. Acute inferior – posterior MI

  14. ST-segment depression in V1-3 With flipped EKG  ST elevation “inverted reflection” ST-depression in V1-3

  15. A recent case – circ stent

  16. Evolving posterior MI with tall R-V2

  17. Case 3. 65-yo woman with 90 mins severe substernal chest pain earlier

  18. Wellens’ warning • Left anterior descending (LAD) • Associated with changes V2-4 • Deeply inverted T waves • Biphasic T waves • Change from initial normal EKG • During pain-free interval • Normal enzymes

  19. Wellens’ syndrome

  20. Wellens’ syndrome, type 2

  21. Wellens’ original description - 1982 • 18% of admitted unstable angina • 50% on presentation • Remainder within 24 hours • If NOT revascularized  75% large anterior MI …within weeks

  22. 60-year-old man with chest painearlier in the day

  23. ECG from 1 month prior

  24. Previous EKG Presentation

  25. One week later…

  26. Case 4. 60-yo man with chest pain

  27. de Winter’s sign • Persistent hyperacute T’s • ST-segment depression • Proximal LAD occlusion • 2% of anterior MIs • 30/1532 anterior MI de Winter NEJM 2008 Verouden Heart 2009

  28. In conclusion… Remember these STEMI equivalents

  29. In conclusion… • Critical left main occlusion • ST-depression ≥ 8 leads • ST-elevation aVR

  30. In conclusion… • Critical left main occlusion • Isolated posterior MI • ST-depression in V2-3 • Evolving tall R in V1-2

  31. In conclusion… • Critical left main occlusion • Isolated posterior MI • Wellens’ warning • Inverted or biphasic T waves V2-3 • An impending anterior MI

  32. In conclusion… • Critical left main occlusion • Isolated posterior MI • Wellens’ warning • de Winter’s sign • Persistent hyperacute T waves • ST depression

  33. ESC STEMI Guidelines Europ H J 33:2569, 2012 • Specifically address: • Isolated posterior infarction • Left main coronary obstruction

  34. www.TorreyEKG.com @STorreyMD

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