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The STEMI Myth: Coronary Occlusion and High-Risk EKGs that Require Reperfusion Charles Bruen, MD resusreview.com/RegionsIMMar16

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Page 1: The STEMI Myth: Coronary Occlusion and High-Risk EKGs that ......nosis is in doubt based upon the 12-lead ECG [37]. Fig. 6 was obtained from a 54-year-old woman with chest discom-fort

The STEMI Myth: Coronary Occlusion and High-Risk EKGs

that Require Reperfusion

Charles Bruen, MD

resusreview.com/RegionsIMMar16

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resusreview.com

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Beware Dichotomies

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Thrombi Dynamic

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Occlusion vs Obstruction

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STE Sensitivity for Occlusion

75%

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Ruled in NSTEMI

25% with occlusion

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Reperfusion• Nondiagnostic ECG, +troonn and ongoing pain

• Subtle ischemic STE

• Hypracute T-waves

• STEMI Mimics

• Dyamic ST segments and T-waves

• STEMI equivalant

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Reperfusion

Acute thrombosis in a coronary artery causing persistent ischemia that is refractory to medical management

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ESC• Patients at very high risk

• Refractory angina

• Severe heart failure

• Life threatening ventricular arrhythmias

• Hemodynamic instability

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ESC• “Such patients may have evolving

MI and should be taken for invasive evaluation (<2H) regardless of ECG or biomarker findings”

• You can do it just on your clinical suspicion

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AHA/ACC 2013 Guidelines

• mm Criteria

• True posterior MI or STE in aVR

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TIMACS

16 vs 52 hours

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What Do We Do

• Serial ECGs

• Cardiac US

• Proportionality

• Know your ECGs

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Hyperacute T-waves

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STEMI Mimics

• LVH

• BER

• LBBB

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Benign Early Repolarization?

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LBBB or MI?

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Isolated Posterior Wall MI

artery, and are respectively termed right and left dominant patternsof circulation. In a smaller percentage of people, arterial supply of theposterior wall is shared by smaller branches of the RCA and LCx, a pat-tern known as codominant circulation [32]. Thus, posterior wall infarc-tion arises due to occlusion of either the RCA or the LCx. However,identification of posterior wall myocardial infarction (PMI) from theperspective of the 12-lead ECG often proves to be challenging, as thisarea of the left ventricle may not be adequately imaged using the tradi-tional approach of seeking STE and using standard leads. For this reason,it is believed that PMI is one of themost frequentlymissed ECG patternsrepresenting AMI [33].

Although PMI often occurs in conjunctionwith acute lateral and/or in-ferior infarctions, ECG manifestations of isolated PMI include the follow-ing in leads V1-V4: (1) horizontal STD; (2) upright T waves; (3) a tall,wide R wave; (3) an R-to-S wave ratio of greater than 1.0 in lead V2

[32,33]. When observing this pattern, it is interesting to note the STD,tall R waves, and upright T waves seem to represent STE, Q waves, andinverted T waves seen when the classic STEMI pattern is flipped 180°[33]. Despite this, STD in the precordium is more typically seen in non–ST-segment elevation MI of the anterior wall of the left ventricle [34].

A prospective study byBoden et al [34] consisting of 50 patientswithisolated STD greater than 1 mm in 2 or more consecutive precordialleads sought to identify ECG features that could help differentiate be-tween PMI and anterior non-MI ACS. This group noted significantlyhigher elevations in mean biomarker levels and a greater degree of pre-cordial STD in leads V1-V3 (P b .01) in the 40% of patients who werefound to have PMI as compared to the remaining patients who werefound to have only anterior non-MI ACS. Furthermore, all 23 patientsin the PMI group were noted to have horizontal STD and upright Twaves, whereas the remaining 27 patients had downsloping STD andT-wave inversions.

As was previously suggested, the diagnostic challenge posed by theidentification of isolated PMImaywarrant the use of expanded ECG tech-niques when the diagnosis remains in question. One suchmodality is theuse of the 15-lead ECG, with posterior leads V7-V9 being placed on thefifth intercostal space at the posterior axillary, midscapular, andparaspinal lines of the posterior left thorax, respectively [35]. A study rep-licating posterior wall AMI, using temporary balloon occlusion of the LCx,demonstrated that posterior lead STE of 0.5 mm or greater (74% vs 38%)or 1mmor greater (62% vs 34%)was very suggestive of acutemyocardialinfraction [36]. These additional posterior leads can aid in the diagnosis incertain presentation and should be considered by the clinician if the diag-nosis is in doubt based upon the 12-lead ECG [37].

Fig. 6 was obtained from a 54-year-old woman with chest discom-fort. The ECG demonstrates normal sinus rhythm with STD in leads V2

to V4. In addition, prominent R waves are noted in leads V2 and V3

along with upright T waves in leads V2 to V4. These findings are recog-nized as consistent with acute posterior wall AMI. The patient wastaken to the catheterization laboratory,with PCI of a distal LCx artery oc-clusion successfully stented.

7. Conclusion

Although the STEMI pattern is the most widely known and easilyidentifiable ECG pattern indicating the presence of significant ischemiawith impending infarction [3], it is important for the emergency physi-cian to recognize other high-risk ECG markers of ACS. Although thesepatterns do not always indicate a time-sensitive, high-risk ACS event,these findings can indicate a potentially more serious form of ACS.Through understanding and identification of these 5 discussed ECG pat-terns, practitioners may recognize high-risk patients who would other-wise be diagnostically “missed” or, at least, not managed in a time- andmedically appropriate fashion.

References

[1] Verouden NJ, Wellens HJ, Wilde AA. A new ECG sign of proximal LAD 367 Q3 occlu-sion. N Engl J Med 2008;359:2071–3.

[2] Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, BlahaMJ, CushmanM, et al. Heart Dis-ease and Stroke Statistics—2015 Update: a report from the American Heart Associa-tion. Circulation 2014;131:e29-322.

[3] Li RA, Leppo M, Miki T, Seino S, Marban E. Molecular basis of electrocardiographicST-segment elevation. Circ Res 2000;87:837–9.

[4] Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD. Third universaldefinition of myocardial infarction. Clin Biochem 2013;46:1–4 [375].

[5] BradyWJ, Roberts D, Morris F. The nondiagnostic ECG in the chest pain patient: nor-mal and nonspecific initial ECG presentations of acute MI. Am J EmergMed 1999;17:394–7.

[6] Erling BF, Perron AD, Brady WJ. Disagreement in the interpretation of electrocardio-graphic ST segment elevation: a source of error for emergency physicians? Am JEmerg Med 2004;22:65–70.

[7] Durant E, Singh A. Acute first diagonal artery occlusion: a characteristic pattern of STelevation in noncontiguous leads. Am J Emerg Med (in press).

[8] Levin DC, Harrington DP, Bettman MA, Garnic JD, Davidoff A, Lois J. Anatomic Varia-tions of the coronary arteries supplying the antero-lateral aspect of the left ventricle(LV)—possible explanation for the “unexplained” anterior aneurysm. Invest Radiol1982;17:420–7.

[9] Sclarovsky S, BirnbaumY, Solodky A, Zafrirb N,Wurzela M, Rechavia E. Isolatedmid-anterior myocardial infarction: a special electrocardiographic sub-type of acutemyocardial infarction consisting of ST segment elevation in non-consecutive leadsand two different morphologic types of ST segment depression. Int J Cardiol 1994;46:37–47.

[10] Iwasaki K, Kusachi S, Kita T, Taniguchi G. Prediction of isolated first diagonal branchocclusion by 12-lead electrocardiography: ST segment shift in leads I and AVL. J AmColl Cardiol 1994;23:1557–61.

[11] BirnbaumY, Hasdai D, Sclarovsky S, Herz I, Strasberg B, Rechavia E. Acutemyocardialinfarction entailing ST-segment elevation in lead AVL: electrocardiographic differen-tiation among occlusion of the left anterior descending, first diagonal, and first ob-tuse marginal coronary arteries. Am Heart J 1996;131:38–42.

[12] Verouden NJ, Koch KT, Peters RJ, Henriques JP, Baan J, van der Schaaf RJ, et al. Persis-tent precordial “hyperacute” T waves signify proximal left anterior descending ar-tery occlusion. Heart 2009;95:1701–6.

[13] Zhong-Qun Z, Nikus KC, Sclarovsky S. Prominent precordial T waves as a sign ofacute anterior myocardial infarction: electrocardiographic and angiographic correla-tions. J Electrocardiol 2011;44:533–7.

[14] Goebel M, Bledsoe J, Orford JL, Mattu A, BradyWJ. A new ST-segment elevationmyo-cardial infarction equivalent pattern? Prominent T wave and J-point depression inthe precordial leads associated with ST-segment elevation in lead AVr. Am J EmergMed 2014;32:287.e5–8.

[15] Engelen DJ, Gorgels AP, Cheriex EC, De Muinck ED, Oude Ophuis AJ, Vainer J, et al.Value of the electrocardiogram in localizing the occlusion site in the left anterior

Fig. 6. Normal sinus rhythmwith STD in leads V2 to V4. In addition, prominent R waves are noted in leads V2 and V3 along with upright T waves in leads V2 to V4. These findings are con-sistent with acute posterior wall AMI.

6 M. Macias et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx

Please cite this article as:Macias M, et al, The electrocardiogram in the ACS patient: high-risk electrocardiographic presentations lacking anatom-ically oriented ST-segment e..., Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.11.047

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Wellens Syndrome

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Anterolateral Wall MI

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D1 and RI

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aVR STE

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aVR STE

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de Winter Waves

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de Winter Waves

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de Winter Waves

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Pseudo-normalization

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Pseudo-normalization

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