ECG in Emergency Department -Advances in ACS ECG. Lecture presented by Dr Hesham Ibrahim at the Egyptian Critical Care Summit , the leading educational event and medical exhibition in Egypt.
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ECG in Emergency Department - Advances in ACS ECG
1. ECG in ED
âAdvances in ACS
ECGâ
By
Hesham A.K.Ibrahim,
MCEM, EgFEM,
ED Registrar, Poole Hospital, UK.
2. - To Discuss the value of ST elevation in aVR.
- To learn how to anticipate ST elevation
before it happens.
- To learn how to diagnose STEMI on top of
BBB & in paced rhythm.
- To learn how to differentiate between STEMI
& Pericarditis ECG.
Objectives
7. âKey informationâ
(American College of Cardiology Foundation/AHA)
â2013 guidelinesâ
point.-STE should be measured at the J-
ânot 40 msec after itâ
Diagnostic ST elevation is defined as:-
STE of 1 mm or more in at least 2 contiguous leads
(except V2-V3) in absence of LBBB or LVH.
:3V-2Regarding V-
- in males, should be 2 mm or more.
- in females, should be 1.5 mm or more.
11. âaVRâST Elevation in
1) ST elevation in aVR.
2) ST elevation in V1 (< STE in aVR).
3) ST depression in most of the chest & limb leads.
12. )3)(2(âaVRâValue of ST elevation in
In ST elevation in aVR + ST depression in
multiple other leads, PLEASE consider:
1) LMCA occlusion, especially if:
- ST elevation in aVR > V1.. (highly specific)
- ST elevation in aVR & aVL..
2) Proximal LAD occlusion.
3) Triple vessel disease.
13. Why is it BAD?
1) ST elevation in aVR is directly proportionate
to the mortality rate:
- 0.5 mm 10.8 %
- 1 mm 13.8 %
- 1.5-2.5 mm 22.2 %
- > 3 mm 50 %
2) Mortality is 70% without immediate PCI.
3) Medical treatment including thrombolysis
does not improve the mortality!!!
14. 4) Emergency PCI may decrease the mortality
to 40%.
5) Time delay to PCI is the only predictor of
survival. (consider early transfer)
15. Some cardiology literatures recommended
ânot to give Clopidogrilâ in presence of
ST elevation in aVR as the patient most
probably will need a surgical intervention
(urgent CABG surgery).
âKosuge, American Journal Cardiology, 2011â
20. âExclusionsâ
1) In presence of SVT & rapid AF, it is expected
to see STE in aVR & diffuse STD.
(transient)
2) Significant HTN causes non specific ST
changes including STE in aVR due to
increased myocardial strain.
3) When there is QRS widening in LBBB &
sever LVH.
4) Asymptomatic patients or patients with no ST
changes of ischemia.
22. âCase 1â
58 years old male patient presented to ED
with a history of cardiac sounding chest pain
12 hours before presentation
He is now pain free..
His 12 hours Troponine is negative..
No old ECGs..
This is his ECG now,,,
24. - First described by Dr. Hein Wellens in 1982.
in thespecific T wave changesIt describes a-
mid precordial leads (V2-5).
- Highly specific for sever stenosis in proximal
.LAD
25. Diagnostic Criteria
1) Deeply-inverted or biphasic T waves in V2-3 (may
extend to V1-6).
2) Isoelectric or minimally-elevated ST segment
(<1mm).
3) No precordial Q waves.
4) Preserved precordial R wave progression.
5) Recent history of angina.
6) ECG pattern present in pain-free state.
7) Normal or slightly elevated serum cardiac markers.
Rhinehart et al (2002)
26. - 75% of the patients will develop anterior
wall STEMI within few weeks if treated
medically (5).
- Present in 2 patternsâŚ
27. (A):1Type
- Deep & symmetric T wave inversion in the mid-
precordial leads.
- More common (75%).
(B):2Type
- Biphasic T wave in the mid-precordial leads.
- Less common (25%).
N.B.
The T waves evolve over time from the symmetrical to the
biphasic pattern.
28. N.B.
There is a confusion in the literature regarding
the naming of the T wave patterns, with some
authors using Type 1 for inverted T waves and
Type 2 for biphasic.
It may be better to just describe the T wave
pattern!
38. - First Described by De Winter & Wellens in 2008
in an article in The New England Journal of
Medicine.
It is:-
J point depression + up sloping ST segment +
tall symmetrical T waves + in precordial
leads. (similar to hyperkalaemia)
39. âValue of De Winter signâ
âAcute Proximal LAD occlusionâ
- Possibly a new indication for cath lab
activation as STEMI equivalent.
(not in the guidelines yet).
proximal LAD occlusion,,subacute,,$Wellens-
treat urgently..
proximal LADacute,,De Winter sign-
occlusion,, treat emergently.
43. - Hyperacute T-wave changes may be observed
in the very early phase of STEMI, before the
development of ST elevation. (1)
- Straightening of the upslope of the T wave is an
early sign that you can use to anticipate ST
elevation.
- Get Serial ECG.
45. âCase 1â
67 years old female patient presented to ED
with a cardiac sounding chest pain.
She is known to have LBBB.
This is her ECG,,,
46.
47. Note absence of âseptal-qâ in V6; andT wave pointing
in direction opposite to QRS (2ď° repolarization effect)
Broad
S wave
Broad
R wave
(Lead I
similar)
Complete LBBB Pattern
V1 V6
54. Criteria of RBBB
1) Wide complex.
2) Tall R or RSRâ in V1.
2) Wide S wave in lateral leads.
3) ST depression & T wave inversion in V1-3.
Any ST elevation in RBBB is always
abnormal.
58. âCaseâ
33 years old male patient presented to ED with
chest pain continuous for the last 6 hours.
central, dull, more with inspiration, notPain was
related to a specific position or a particular
movement, non reproducible.
His observations at presentation were:
BP: 125/82 P: 110 Temp: 37 RR: 18
Sat: 98%
An ECG was requested.
62. Approach to differentiate STEMI
from acute Pericarditis
Is it STEMI??)1
â5 signs to checkâ
??pericarditisIs it possible acute)2
â5 signs to checkâ
63. Factors that strongly favor
STEMI (5)
1) Presence of reciprocal changes,
(ST Depression other than in aVR & V1).
2) STE III > STE II (progressive â sign of RCA lesion).
3) ST elevation is not concave, i.e convex or
horizontal âalthough it could be concaveâ.
4) New Q waves.
5) âCheckmark signâ
i.e.QR-T sign (expert opinion)
64. Factors that strongly favor
Pericarditis (5)
1) Widespread ST elevation & PR segment
depression in most of the limb leads & in
V2-V6.. (This discordance is characteristic)
2) ST elevation is concave upwards (saddle
shape).
3) Reciprocal ST depression & PR segment
elevation in aVR & V1.
4) Spodickâs Sign.
5) Sinus tachycardia, due to pain +/_ effusion.
70. Never to consider Pericarditis
in presence of:
- ST depression other than in aVR & V1.
- Convex or horizontal ST elevation.
If in doubt:
âSerial ECGsâ
71. Value of Serial ECGs
- 11% of patients with STEMI present with non
diagnostic ECGs.
- 72% of them develop ST elevation within
90 min.
Riley RF, Newby LK, Don CW, et al. Diagnostic time course, treatment, and in-
hospital outcomes for patients with ST-segment elevation myocardial
infarction presenting with non-diagnostic initial electrocardiogram: A report
from the American Heart Association Mission: Lifeline program. Am Heart J.
23237133. PMID:56â50):1(165;2013
72. âAmal Mattu, MD, FAAEM, FACEPâ
Professor of Emergency
Medicine.
University of Maryland.
Baltimore, Maryland, USA.
73. Summary
- Take care of the value of ST elevation in aVR.
- Always keep in mind Wellensâs $, De Winter sign
& the the ST-T wave changes as signs that you can
use to anticipate ST elevation.
- You can use Sgarbossa criteria to diagnose STEMI
on top of LBBB & in paced rhythm.
- Always have an approach to differentiate between
STEMI & acute pericarditis ECG & never to
consider pericarditis in presence of ST depression.
74. References
(1) 2013 ACCF/AHA Guideline for the Management of ST Elevation Myocardial
Infarction.
(2) Barrabes JA, Figueras J, Moure C, Cortadellas J, Soler-Soler J. Prognostic
value of lead aVR in patients with a first non ST-segment elevation acute
myocardial infarction. Circulation 2003; 108: 814 â 819
(3) Aygul N, Ozdemir K, Tokac M, Aygul MU, Duzenli MA, Abaci A et al. Value
of lead aVR in predicting acute occlusion of proximal left anterior
descending coronary artery and in-hospital outcome in ST
elevation myocardial infarction: an electrocardiographic predictor of poor
prognosis. J Electrocardiol. 2008 Jul-Aug;41(4):335-41
(4) Wellen's syndrome: An ominous EKG pattern Nicole E Mead, Kelly P
O'Keefe. J Emerg Trauma Shock. 2009 Sep-Dec; 2(3): 206â208.
(5) De Zwaan C, Bar FW, Wellens HJ. Characteristic electrocardiographic
pattern indicating a critical stenosis high in left anterior descending
coronary artery in patients admitted because of impending myocardial
infarction. Am Heart J. 1982.
(6) De Winter R, Verouden N, Wellens H, Wilde A. A new ECG sign of proximal
LAD occlusion. N Engl J Med 2008;359:2071â3.
75. (7) Goebel M, Bledsoe J, Orford JL, Mattu A, Brady WJ. A new ST-segment
elevation myocardial infarction equivalent pattern? Prominent T wave and
J-point depression in the precordial leads associated with ST-segment
elevation in lead aVr. Am J Emerg Med. 2014 Mar;32(3):287
(8) Sgarbossa EB, Pinski SL, Barbagelata A, Underwood DA, Gates KB, Topol
EJ, Califf RM, and Wagner GS. Electrocardiographic diagnosis of
evolving acute myocardial infarction in the presence of left bundle-branch
block. GUSTO-1 (Global Utilization of Streptokinase and Tissue
Plasminogen Activator for Occluded Coronary Arteries) Investigators. N
Engl J Med 1996 Feb 22; 334(8) 481-7.
(9) Klimczak A, Wranicz JK, Cygankiewicz I, Chudzik M, Goch JH, and
Baranowski R. Electrocardiographic diagnosis of acute coronary
syndromes in patients with left bundle branch block or paced rhythm.
Cardiol J 2007; 14(2) 207-13. pmid:18651461.
(10) Chan TC, Brady WJ, Harrigan RA, Ornato JP and Rosen PR. ECG in
Emergency Medicine and Acute Care. Elsevier 2005
(11) Mattu A, Brady W. ECGs for the Emergency Physician 2, BMJ Books
2008.
(12) Surawicz B, Knilans T. Chouâs Electrocardiography in Clinical Practice (6th
edition), Saunders 2008.