Pitfalls in Diagnosing ACS /MI

DR Omran
ST3 Emergency medicine trainee
MRCP/MRCPI/MRCEM
 Disclosure

I have nothing to disclose

 Objectives
 To discuss some of the ECG pitfalls in
diagnosing ACS/MI
 To discuss the pitfalls in the clinical diagnosis
of ACS/MI
Why are we missing ACS/MI ?
• Generally speaking there is 2 rules when it
comes to When it comes to diagnosing
ACS/MI
1- you can not diagnose all the cases of AC/SMI
2-you can not change rule number one
ECG pitfalls
What is the ECG definition of ACS /MI ?
So what is the definifition ?
• 5-20 % will have normal intial ECG
• 20 of MI will be diagnosed in the second
/following ECG
• The incidence of AMI with a normal ECG was
3.7% : patient with normal initial ECG and
remained to have normal ECG (NCBI) .
• The earliest findings on an ECG are subtle
changes in the T-wave shape and size. When
a coronary artery is occluded, within the first
30 minutes, the T-wave amplitude increases
• The straightening or loss of convexity of the ST
segment ( Amal mattu)
• Hyperacute T-waves in AMI
• The de Winter T-wave pattern
• Pseudonormalization of T-waves
 Conclusions
The default management plan for any patient
presenting with acute anterior chest pain that
could potentially be of ischaemic origin, who
has either a normal or non-specifically
abnormal ECG, should be a period of
observation and re-evaluation.
• Clinical significance
• Patients may be pain free by the time the ECG is
taken, and have normal or minimally elevated
cardiac enzymes. However, they are at extremely
high risk for extensive anterior wall MI within the
subsequent days to weeks
• Due to the critical LAD stenosis, these patients
usually require invasive therapy, do poorly with
medical management, and may suffer MI or cardiac
arrest if inappropriately stress tested
• de Winter syndrome is a special equivalent of
anterior ST-segment elevation myocardial
infarction (STEMI) characterized by the
absence of overt ST-elevation with upsloping
ST-segment depression followed by tall
symmetrical T-waves in the precordial leads,
often associated with total occlusion of the
proximal left
• ECG Diagnostic Criteria
• Tall, prominent, symmetrical T waves in the precordial
leads
• Upsloping ST segment depression > 1mm at the J point
 in the precordial leads
• Absence of ST elevation in the precordial leads
• Reciprocal ST segment elevation (0.5mm – 1mm) in aVR
• Typical STEMI morphology may precede or follow the
De Winter pattern
• Messages to take home
• Know your definition