Doubtful Acute Coronary Syndrome ECG

&
How to Refer Px

MY Alsagaff MD PhD
 Outline
Introduction & Definition
• Acute Coronary Syndrome Vs Myocardial Infarction
• ECG of STEMI
• STEMI Equivalent Vs Mimics
STEMI Equivalents ECG
• Isolated Posterior
• Hyperacute T
• RBBB STEMI
• aVR STEMI
• LBBB STEMI
• RV Pacing
Future Directions
• De Winter
• Wellen A & B
• Delayed Activation Wave ( N Wave )
Take Home Messages
Introduction & Definition
Make Sure You are Updated
European Heart Journal (2018) 00, 1–33
 Working Diagnosis
Acute Coronary Syndrome
(UA/NSTEMI/MI) Myocardial Infarction
( STEMI/NSTEMI )
Symptoms based
Hs-Troponin Based

• Chest Pain
• Prolonged (20 min) anginal pain at
rest; ( 80% ) • Any reasons for excluding acute coronary
• New onset (de novo) angina (CCS II or syndrome in Emergency Word
III ) ( +20% ) • High Sensitivity ( CKMB no longer
• Crescendo angina (Recent recommended )
destabilization of previously stable, ≥ • Organ Specific not disease specific
CCS III ) (+20% )
• Post MI
• Chest pain equivalent : Chest Discomfort,
Dyspnea, epigastric pain, pain in the left arm

European Heart Journal (2020) 00, 179

 Working Diagnosis
Acute Coronary Syndrome Myocardial Infarction
(UA/NSTEMI/MI)
Hs-Troponin Based
Sign and Symptoms based
HOW DOES ST-T CHANGES HAPPEN ?

• Ischemia & Injury → the repolarization phase (Phase 2) →

ST - Segment
• Direction of current of ST vectors with acute ischemia :
A. SUBENDOCARDIAL ISCHEMIA : resultant ST-vector moves
toward the INNER LAYER of affected ventricle. Overlying
ECG lead → ST depression
B. TRANSMURAL /EPICARDIAL INJURY : ST-vector is directed
OUTWARD. ECG leads overlying → ST-segment elevation.

Zipes, DP, Libby P., et al. 2019. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 11th Edition.
Electrocardiography. Elsevier : USA
THE CONCEPT OF INJURY VECTOR:
DIRECT & RECIPROCAL CHANGES

• In STEMI : ST-depression frequently recorded

in leads OPPOSITE to injured area (reciprocal
patterns).
• HOW ABOUT ISCHEMIA? WHY NO ST-
Elevation RECIPROCAL ? Not enough
resultant!
• Reciprocal Leads : VERY helpful in locating
culprit area (Side Image)

de Luna B, Flol-Sala M., Antman EM. 2007. The 12-Lead ECG in ST Elevation Myocardial Infarction.
Blackwell : USA
https://emtprep.com/free-training/post/intro-to-12-lead-ecg-interpretation
 HOW DOES ST-ELEVATION HAPPEN ?

Ischemia & Injury → Cardiomyocyte hypoxia → loses ATP-gated Na/K pumps (K cannot escape)
• affects repolarization phase (Phase 2 Cardiac Action Potential) → ST - Segment
Zipes, DP, Libby P., et al. 2019. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 11th Edition. Electrocardiography. Elsevier : USA
Pratanu S.Kursus Elektrokardiografi Edisi ke-6. April 2017.
 • Achieving the shortest possible time to revascularization is the CORNERSTONE of acute
myocardial infarction (MI) with ST-segment elevation MI (STEMI) management.

• Wall, et al (2016) : 1429 NSTEMI patients → Appr. 10% - 25% of NSTEMIs with ‘STEMI equivalent’
ECG changes correlated with complete vessel occlusion on angiography.

• Topic Aim : review most common STEMI equivalents & brief STEMI Mimic ECGs

Wall, J., White, L.D. & Lee, A. 2016. Novel ECG changes in acute coronary syndromes. Would improvement in the recognition of ‘STEMI-equivalents’ affect time until reperfusion?. Intern Emerg Med 13, 243–249

Tzimas G, Antiochos P, Monney P, et al. Atypical Electrocardiographic Presentations in Need of Primary Percutaneous Coronary Intervention. Am J Cardiol. 2019;124(8):1305-1314.
 STEMI EQUIVALENT S
• FALSE NEGATIVE
• ECG and Clinical settings
atypical
• High Risk Population
• Delayed Reperfusion
• Poor Outcome & Mortality
STEMI MIMIC S
• FALSE POSITIVE
• ECG seem typical
• In risk of unnecessary
complications
• High-cost and hospital
burden
• Delayed optimal therapy
STEMI Equivalents ECG
Should Prompt Reperfusion
 Pay Attention & Consult in Doubt

PPCI Confident Evolving Criteria

(ESC &/ AHA
approved)
• Hyperacute T- • deWinter’s sign
waves (AHA) • Wellens’
• Isolated syndrome
Posterior MI • Delayed
• STEMI in RBBB Activation Waves
• aVR STEMI
• STEMI in LBBB Clinical& Serial
(Modified HsTrop
Sgarbossa)
• RV Pacing STEMI Cardiologist
(ESC) Consultation is
needed
1. A 47 year-old man, presented with acute, dull, typical chest pain since 30 minutes
ago

a. Hyperacute T-wave in the inferior

leads
b. Anterolateral ischemia
c. Poor R wave progression, suggestive
of OMI in the anteroseptal
d. Digoxin toxicity
e. DeWinter’s sign
Hyperacute T
Reperfusion ASAP
 HYPERACUTE T-WAVE

• Precursor sign of STEMI & impending coronary occlusion.

• Definition: T waves with a broad/fat base, symmetrical, high peak, often accompanied by J-point
depression. Mostly visible in precordial leads.

• The mechanism hypothesized : preservation of coronary flow by sub-occlusion or coronary

occlusion with additional blood supply via collateral vessels → increase the endoepicardial
repolarization voltage gradient → characteristic high T wave and peaking image.

• Usually transient → rapid evolve to ST elevation. Perform serial ECGs!

Zorzi A, et al.. Interpretation of acute myocardial infarction with persistent ‘hyperacute T waves’ by cardiac magnetic resonance. Eur Heart J Acute Cardiovasc Care 2012;1:344–348
 Case Presentation

(1A) Baseline ECG in a 51 year-old patient with acute onset of chest pain, showing hyperacute T waves
without ST segment deviation.
(1B) 2nd ECG performed 4 hours later due to persistent chest pain, currently showing Q waves in
leads V1-V3, triggering coronary angiography strategy.

Tzimas G, Antiochos P, Monney P, et al. Atypical Electrocardiographic Presentations in Need of Primary Percutaneous Coronary Intervention. Am J Cardiol. 2019;124(8):1305-1314.
2. A 56 year old woman came to the ER with shortness of breath, heartburn and nausea
since 3 hours ago.

a. Isolated Posterior Myocardial Infarct

b. deWinter’s sign
c. Ischemia in the anterior region
d. Hyperkalemia
e. STEMI AVR
Isolated Posterior
It is not an ischemia
 Case Presentation 1

60yo female with a history of smoking, presented with of typical chest pain for 3 hrs.

Isolated ST-depression ≥
0.05 mV in V1-V3

ST elevation
≥ 0.05 mV in V7-V9
(≥ 0.1mV in men, age < 40 years)
(A) Sinus rhythm with ST-segment depressions in leads V1 - V4, with a positive terminal T wave and a large
R wave in leads V2 and V3 , an appearance suggestive of posterior-wall ischemia.
(B) A posterior lead ECG revealed ST-segment elevation in leads V7, V8, and V9 .

Briosa e Gala, A., & Rawlins, J. (2019). Posterior-Wall Myocardial Infarction. New England Journal of Medicine, 381(17), e32. doi:10.1056/NEJMicm1901367
 Case Presentation 1

C D

(C) Emergency coronary angiography was performed. Occlusion of the proximal LCx coronary
artery and the 1st obtuse marginal artery was visualized (arrow)
(D) Occlusion treated with a drug-eluting stent.
Briosa e Gala, A., & Rawlins, J. (2019). Posterior-Wall Myocardial Infarction. New England Journal of Medicine, 381(17), e32. doi:10.1056/NEJMicm1901367
 ISOLATED POSTERIOR
MYOCARDIAL INFARCTION

• MI in the inferior & basal regions -- “true” occlusion from RCA or LCx – ISOLATED ST DEPRESSION
of ≥ 0.05 mV in V1-V3 → should be treated as STEMI !

• 4th Univ. Definition (ESC 2018) : Use posterior chest leads [ST elevation ≥ 0.05mV in V7-V9; ≥
0.1mV in men, age < 40 years] is recommended.

• Study by Khan et al, 79 from 177 (68%) physicians failed to diagnose isolated posterior MI, with
slower door-to-balloon time

• Urgent need to perform RV & Posterior lead ECG in ACS pts with normal ECG

Thygesen, K., Alpert, J. S., Jaffe, A. S, et al. 2018. Fourth universal definition of myocardial infarction. European Heart Journal (2019) 40, 237–269
Khan JN, Chauhan A, Mozdiak E, Khan JM, Varma C. Posterior myocardial infarction: are we failing to diagnose this. Emerg Med J 2012;29:15–18.
A primary PCI strategy (emergent coronary angiography and PCI if indicated) should be
considered when persistent ischaemic symptoms occur in the presence of RBBB.
3. Male, 75 yo, Chest Pain 4 hours

a. RBBB + STEMI Anterior

b. STEMI anteroseptal
c. aVR STEMI
d. CRBBB
e. CLBBB
RBBB STEMI
PPCI is indicated
The presence of RBBB may confound the diagnosis of STEMI
 RIGHT BUNDLE BRANCH BLOCK (RBBB)

• STEMI + new onset RBBB → poor prognosis, culprit lesions in proximal LAD

• Widimsky et al (ESC 4th Univ. Def) → New RBBB without ST elevation/T-wave changes 66% have
TIMI flow 0 to 2 in follow-up DCA (versus >90% in new RBBB + ST elevation/T changes).

• In a study of 4,067 ACS pts, MI persisted in 21% of patients with RBBB, 29% LBBB, and 23%
bifascicular block → 1-year mortality rate was 11% for RBBB, 7% for LBBB, and 18% for
bifascicular block.

• PPCI strategy should be considered when ischemic symptoms persists in the presence of RBBB.

Neumann JT, et al. Right bundle branch block in patients with suspected myocardial infarction. Eur Heart J Acute Cardiovasc Care 2018. 2048872618809700.

Tzimas G, Antiochos P, Monney P, et al. Atypical Electrocardiographic Presentations in Need of Primary Percutaneous Coronary Intervention. Am J Cardiol. 2019;124(8):1305-1314.
 Hour 0 Hour 3

Middle Age Man,Sudden onset of Chest Pain 8/10, Bp 160/102 HR 72

BMJ Case Rep. 2015; 2015: bcr2015209435.

 Case Presentation

67yo male with a history of hypertension and smoking, presented with of right-sided dull chest pain
for 6hrs. VAS 7/10, and radiating to his right shoulder and jaw.

ECG (a) Prior to presentation ECG (b) On presentation, demonstrating a The right coronary
new RBBB. artery is completely
occluded in the proximal
segment (arrow)

Pozen JM, Mankad AK, Owens JT, Jovin IS. New Right Bundle Branch Block as a Criterion for Emergent Coronary Angiography. N Am J Med Sci. 2015;7(12):569-571. doi:10.4103/1947-
2714.172849
BREAK
 5. A 58-year old man came to the ER
4. A 37 year old man came to the outpatient clinic with chest pain and shortness of
with heartburn and nausea since 2 days ago.
breath since 7 hours ago.

a. Complete RBBB
b. Common Complete LBBB a. Complete RBBB
c. Intraventricular branch block b. Inferior STEMI
c. Common Complete LBBB
d. Complete LBBB with STEMI in d. Intraventricular branch block
anteroseptal region e. Complete LBBB with STEMI in anterior-inferior region
e. STEMI AVR
LBBB STEMI
PPCI is indicated
 • A score of ≥3 points =
Specificity > 95%, but
Sensitivity 31- 73%

→ Thus, the Sgarbossa criterion is

NOT for RULE-OUT
myocardial infarction, but
CAN BE USED FOR RULE-IN

Sgarbossa EB, Pinski SL, Barbagelata A, Underwood DA, Gates KB, Topol EJ, Califf RM, Wagner GS. Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle- branch block.
GUSTO-1 (Global Utilization of Streptokinase and Tis- sue Plasminogen Activator for Occluded Coronary Arteries) Investigators. N Engl J Med 1996;334:481–487
ECG waves (Book and Courses). ECG and ECHO learning. Left Bundle Branch Block and Acute Myocardial Infarction. https://ecgwaves.com/topic/left-bundle-branch-block-acute-coronary-syndromes-sgarbossa/
Smith SW, Dodd KW, Henry TD, Dvorak DM, Pearce LA. Diagnosis of ST-elevation myocardial infarction in the presence of left bundle branch block with the ST-elevation to S-wave ratio in a modified Sgar- bossa rule.
Ann Emerg Med 2012;60:766–776.
ECG waves (Book and Courses). ECG and ECHO learning. Left Bundle Branch Block and Acute Myocardial Infarction. https://ecgwaves.com/topic/left-bundle-branch-block-acute-coronary-syndromes-sgarbossa/
 LEFT BUNDLE BRANCH BLOCK (LBBB)

• 2016, Smith et al → Modified the 3rd point Sgarbossa

➢ ST segment elevation compared with an S wave depth (ST / S ratio) less than -0.25.

• In that study → improved diagnostic performance for STEMI with a sensitivity and specificity of 91% and
90%.

• Di Marco et al, retrospective analysis of 145 patients with LBBB + MI, the sensitivity was similar to the
original Sgarbossa criterion (67%)

• 2020, BARCELONA algorithm achieved the highest sensitivity (93%–95%), negative predictive value
(96%–97%), efficiency (91%–94%) and area under the receiver operating characteristic curve (0.92–
0.93),
Di Marco A, et al.. Assessment of Smith algorithms for the diagnosis of acute myocardial infarction in the presence of left bundle branch block. Rev Esp Cardiol (Engl Ed) 2016;70:559–566.
https://www.acc.org/latest-in-
cardiology/articles/2017/02/28/14/1
0/lbbb-in-patients-with-suspected-mi
6. A 74 year-old man, came with chest pain radiating to his back since 6 hours ago. He has
a history of sick sinus syndrome.

a. Hyperacute T-waves in the

anteroseptal region
b. Anterolateral STEMI + RV Pacing
c. Normal Pacemaker Rhythm ECG
d. Complete Left Bundle Branch Block
e. Hyperkalemia
RV Pacing
LBBB Pattern
 STEMI in RIGHT VENTRICULAR PACING (RVP)

• Conventional RVP → a ECG morphology similar to LBBB

• Bertel N, et al : 27,985 AMI pts, pacemaker users (n = 300) received less emergency
reperfusion (58.7% vs 82.4%; p <0.001). In-hospital mortality was higher (11.3% vs
4.6%; p <0.001).

• Two approaches (1) pacemaker re-programming (in non-dependent pacemaker

patients, to assess intrinsic rhythm) and / or (2) apply the Sgarbossa criteria.

Bertel N, et al. Management and outcome of patients with acute myocardial infarction presenting with pacemaker rhythm. Int J Cardiol 2017;230:604–609.
 Partial pacemaker rhythm with ST elevation ≥5 mm discordant in the negative paced QRS lead.
Native QRS complex : RBBB morphology with ST elevation and Q waves indicating subacute anterior myocardial infarction.
Coronary angiography shows a thrombotic occlusion at the proximal LAD

Tzimas G, Antiochos P, Monney P, et al. Atypical Electrocardiographic Presentations in Need of Primary Percutaneous Coronary Intervention. Am J Cardiol. 2019;124(8):1305-1314.
 Case Presentation
83yo, male, history of hypertension, hyperlipidemia, ischemic cardiomyopathy, CAD and pacemaker implantation,
typical chest pain for 2 hours.

Presenting ECG revealed concordant > 1 mm ST-segment elevations in the anterolateral leads
Kang W, Ge L D, Patel P, et al. (May 25, 2020) Rare and Fascinating Case of ST-Elevation Myocardial Infarction Diagnosis From an Underlying Ventricular Paced Rhythm. Cureus 12(5): e8274.
doi:10.7759/cureus.8274
 Case Presentation

A B

(A) Severe proximal LAD artery stenosis (90%) with an acute, ulcerated appearance (arrow).
(B) Arrow showing a successful PCI with a drug-eluting stent to the proximal LAD artery (arrow).

Kang W, Ge L D, Patel P, et al. (May 25, 2020) Rare and Fascinating Case of ST-Elevation Myocardial Infarction Diagnosis From an Underlying Ventricular Paced Rhythm. Cureus 12(5): e8274. doi:10.7759/cureus.8274
7. A 67year-old man presented with shortness of breath and pressing chest pain since 3 hours ago.

a. Complete Right Bundle Branch Block

b. deWinter’s sign
c. Complete Left Bundle Branch Block
d. aVR STEMI
e. Old Myocardial Infarct at Anterior
(Poor R-wave progression)
aVR STEMI
PPCI is indicated
 LEFT MAIN CORONARY ARTERY
OBSTRUCTION

• ST depression ≥ 1 mm in 8 or more leads (us. inferolateral ST depression), coupled with ST

elevation in aVR and / or V1 → triple vessel ischemia or left main coronary artery obstruction
• A sensitivity of 78% - 81%, a specificity of 76% - 80% and a PPV 57%.
• Extensive subendocardial ischemia or basal ventricular septal infarction → aVR changes.
• Lab test : cardiac markers should be done, but should not delay reperfusion strategy. Even if
Echo is not available or doubtful diagnosis, a PPCI is still indicated !

Tzimas G, Antiochos P, Monney P, et al. Atypical Electrocardiographic Presentations in Need of Primary Percutaneous Coronary Intervention. Am J Cardiol. 2019;124(8):1305-1314
 LEFT MAIN CORONARY ARTERY
OBSTRUCTION

de Luna B, Flol-Sala M., Antman EM. 2007. The 12-Lead ECG in ST Elevation Myocardial Infarction.
Blackwell : USA
 ECG EXAMPLE

ECG shows a ST elevation-aVR and V1. There was extensive ST depression (1 to 2 mm) in the inferior and antero-lateral leads, and a tall
positive symmetrical T wave in anterior leads persisting during the first 6 hours after admission.
Collet JP, et al; ESC Scientific Document Group. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2020
Aug 29:ehaa575.
Future Direction
Emeregncy Vs Urgent
8. A 71 year-old woman, came in with chest pain her left chest radiating to her arms since 2
hours ago.

a. Hyperacute T Waves in the

anterolateral region
b. Hyperkalemia
c. Digoxin Toxicity
d. STEMI aVR
e. DeWinter’s sign
De Winter
Cold and Deadly
 DE WINTER SIGN

• DeWinter Sign → critical sub-occlusion in the LAD - with ST elevation following

• PPV 95% - 100% for at least 70% angiographic stenosis of major epicardial vessels.

• Introduced in 2008, "de Winter sign" is a combination ECG pattern of:

(1) a high, prominent, symmetrical T wave in the precordial leads

(2) an upsloping ST depression > 1 mm at the J-point in precordial leads

(3) absence of ST elevation in the precordial leads

(4) (often) mild (0.5 to 1 mm) ST elevation in aVR.

de Winter RJ,Verouden NJ,Wellens HJ, et al, Interventional Cardiology Group of the Academic Medical C. A new ECG sign of proximal LAD occlusion. N Engl J Med 2008;359:2071–2073.
 ECG EXAMPLE

'de Winter sign’ ECG above shows up-sloping ST depression at the J-point in leads V2-V6, with prominent T
waves in the precordial leads as well as mild ST segment elevation in the aVR.
Tzimas G, Antiochos P, Monney P, et al. Atypical Electrocardiographic Presentations in Need of Primary Percutaneous Coronary Intervention. Am J Cardiol. 2019;124(8):1305-1314.
 DE WINTER SIGN

• de Winter, et al studied 5,588 ACS patients, "de Winter sign" ECG identified
in 1.6% of pts with anterior MI (11 of 688 patients). Interestingly, 10 of the
11 patients were male and lesions in the proximal or mid LAD were culprit
lesions in all cases.

• Atypical STEMI pattern → significant delay of reperfusion strategy (up to

several days), resulting in 3 of the 11 patients died.

de Winter RW, Adams R, Amoroso G, et al. Prevalence of junctional ST-depression with tall symmetrical T-waves in a pre-hospital field triage system for STEMI patients. J Electrocardiol 2019;52:1–5.
 Case Presentation

53 yo, male, history of smoking and DMt2, complains of typical chest pain and shortness of breath, onset 30 minutes.

(A) ECG before PCI, up-sloping ST depression and peaked T-waves in leads V2-V5. (B) ECG
after PCI
Canakci, M. E., Turgay Yildirim, Ö., Acar, N., & Mert, K. U. (2018). Evaluation of acute anterior myocardial infarction cases with de-Winter T waves by coronary angiography images. Turkish Journal of Emergency Medicine.
doi:10.1016/j.tjem.2018.10.003
 Case Presentation

(C) Total LAD occlusion was present before the PCI.

(D) LAD TIMI flow 3 was achieved after the PCI.

Canakci, M. E., Turgay Yildirim, Ö., Acar, N., & Mert, K. U. (2018). Evaluation of acute anterior myocardial infarction cases with de-Winter T waves by coronary angiography images. Turkish Journal of Emergency Medicine.
doi:10.1016/j.tjem.2018.10.003
9. A 54 year-old female, in the outpatient clinic, complained of typical chest pain she felt 3-4 days
ago, and decided to see a cardiologist afterwards.

a. LVH with strain

b. Isolated posterior STEMI
c. Anterior ischemia
d. Wellen’s syndrome type B
e. Wellen’s syndrome type A
10. A 39 year-old man, presented to the ER with typical chest pain (but the pain comes and
goes) since two days ago.

a. Isolated posterior myocardial infarct

b. Wellen’s syndrome type A
c. Wellen’s syndrome type B
d. Hypokalemia
e. Recent IMA anterolateral
Wellen
Critical
 WELLENS’ SYNDROME

• Wellens' syndrome → critical stenosis (even, total occlusion) of proximal LAD

artery with sensitivity 69% and specificity 89%.

• Classified in NSTEMI High-risk criteria (Early Reperfusion Strategy)

• There are 2 types of T-wave changes Wellens’ Syndrome:

• Type A : biphasic T waves, with initial positivity and terminal negativity in leads V2
and V3 (25% of cases)

• Type B : symmetric deeply inverted T wave inversion in leads V2 and V3. (75% of
cases)
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;103:730–736.
 ECG EXAMPLE

ECG 1 hour later, with ST segment elevation in V2 to V5 and lead I, aVL associated with ST depression in the
inferior lead compatible with anterior MI. Coronary angiography showed 100% occlusion in the proximal LAD
coronary artery.
Tzimas G, Antiochos P, Monney P, et al. Atypical Electrocardiographic Presentations in Need of Primary Percutaneous Coronary Intervention. Am J Cardiol. 2019;124(8):1305-1314.
 Case Presentation

TYPE A Wellens’ Syndrome

ECG shows biphasic T

waves in leads V2 and
V3, continued by T
inversion in V4-V6

Note:
• NO precordial Q
waves
• NO significant ST
changes
• NO poor R wave
progression.
Collet JP, et al; ESC Scientific Document Group. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2020
Aug 29:ehaa575.
Take Home Mesages
 Pay Attention & Consult in Doubt

PPCI Confident (ESC Evolving Criteria

&/ AHA approved)
• Hyperacute T- • deWinter’s sign
waves (AHA) • Wellens’
• Isolated Posterior syndrome
MI • Delayed
• STEMI in RBBB Activation Waves
• aVR STEMI
• STEMI in LBBB Clinical& Serial
(Modified HsTrop
Sgarbossa)
• RV Pacing STEMI Cardiologist
(ESC) Consultation is
needed
Electrocardiography
Bedside Rapid tools -> Urgency of Intervention
 N Wave
We might have missed
 DELAYED ACTIVATION WAVES
(N WAVES)

• 12-lead ECG has low sensitivity especially if the culprit lesion is

LCx
• Niu T., et al (2013) : N-WAVE as a predictor of Total Occlusion in
the LCx artery
• ‘N’ wave definition:
1) notch / deflection in terminal QRS complex
2) notch / deflection is at least 2 mm (reference PR segment)
3) a continuous change of the notch (the point of deflection
shifted at least 2 mm with reference to the PR segment in
at least 2 leads within 24 hours, even disappeared or
merged with the S-wave)
4) prolongation of QRS duration in these leads.

Niu, T., et al. (2013). The delayed activation wave in non-ST-elevation myocardial infarction. International Journal
of Cardiology, 162(2), 107–111.
 DELAYED ACTIVATION WAVES
(N WAVES)

• Niu et al → 218 NSTEMI pts + Cor. Angio

within 24 hours.
• Mechanism : Abnormal waveform in
terminal QRS complex → delayed
activation wave of left ventricular basal
region which the LCx artery supplies.

• Wall et al (2016): N-waves present at 10%

of NSTEMI pts (6 out of 60pts)

Niu, T., et al. (2013). The delayed activation wave in non-ST-elevation myocardial infarction. International Journal
of Cardiology, 162(2), 107–111.
 TAKE HOME MESSAGES
PPCI Confident (ESC &
AHA approved)
• STEMI in LBBB (Modified
Sgarbossa)
• Isolated Posterior MI
• aVR STEMI
• RV Pacing STEMI (ESC)
• Hyperacute T-waves (AHA)
• Depends on clinical settings:
New onset LBBB (without
Sgarbossa) or RBBB
PCI is definite, but
Immediate or Early?
• Treated as NSTEMI (very)
high risk but high suspicion
index is needed:
• deWinter’s sign
• Wellens’ syndrome
• N Wave
• Serial ECG and troponin is a
must !
• Seek consultation with
Interventionist ASAP
 Case Presentation

61yo male, history of smoking and DMt2, presented with chest pain lasting for 60 minutes, had 2 coronary angiography
examinations and one stent implantations before.

(A) ECG before PCI, up-sloping ST depression and peaked T-waves in leads V2-V6. (B) ECG
after PCI

Canakci, M. E., Turgay Yildirim, Ö., Acar, N., & Mert, K. U. (2018). Evaluation of acute anterior myocardial infarction cases with de-Winter T waves by coronary angiography images. Turkish Journal of Emergency Medicine.
doi:10.1016/j.tjem.2018.10.003
 Case Presentation

(1C, 1D) Coronary angiography shows occlusion of the LAD artery, after the 1st septal branch
(yellow arrow).

Tzimas G, Antiochos P, Monney P, et al. Atypical Electrocardiographic Presentations in Need of Primary Percutaneous Coronary Intervention. Am J Cardiol. 2019;124(8):1305-1314.
 ECG EXAMPLE

They are "fat" and wide, with a blunt peak and poor R-wave progression (especially V3).
The T-waves of hyperkalemia are peaked and tented.
Smith SW. 2002. The ECG in Acute MI: An Evidence Based Manual for Reperfusion Therapy. Lippincott & Williams, 2002. Philadelphia, USA