ECG IN STEMI

DR AZERIN OTHMAN
HRPZ II KOTA BHARU
 ROLES OF ECG IN STEMI
• Diagnosis of acute STEMI
• Correlate ECG changes and candidate for reperfusion
therapy
• Assess the success of reperfusion therapy
• Correlate location of MI & extent of myocardial
injury - stratification/prognostication/complications
- optimal treatment
 CLINICAL DIAGNOSIS OF ACUTE STEMI

1.Chest pain or equivalent symptoms or events suggestive ischaemic in origin.

2.ECG changes : Any of the followings (on its own or in any combinations):
 ST elevation in 2 or more contiguous leads of standard 12 lead ECG as follows:

- ≥ 1mm limb leads : I, aVL, II, III, aVF.

- ≥ 1mm precordial leads : V1 & V4 - V6.
- ≥ 2.5mm precordial leads : V2 - V3 . ( males < 40yr )
- ≥ 2.0mm precordial leads : V2 - V3 . ( males ≥ 40yr )
- ≥ 1.5mm precordial leads : V2 - V3 . ( female)

 Posterior Infarction
 RV Infarction
 New onset LBBB
+

3. A rise and fall of serum cardiac markers ( Troponin or CKMB )

3
 ECG CHANGES IN STEMI
1.HYPERACUTE PEAK T WAVE - HYPERACUTE T WAVE
- T waves tall, symmetrical & peaked
- usually present 5- 30 minutes after the onset of STEMI later followed by
ST changes.
 ECG CHANGES IN STEMI
2.ST SEGMENT ELEVATION - HYPERACUTE ST ELEVATION
- commonly seen
- usually within hours after onset of STEMI
- occurs in the leads facing the infarction
 ECG CHANGES IN STEMI
3. PATHOLOGICAL Q WAVE - FULLY EVOLVED PHASE
- at least 0.04 seconds in duration
- depth of more than 25% of ensuing R wave
- usually after 9 hours, occasionally after 24 hours after onset of MI
- evidence of myocardial necrosis
- loss of R wave after 12 hours
 ECG CHANGES IN STEMI

4.RESOLUTION OF ST ELEVATION & T WAVE INVERSION - RESOLUTION PHASE

- ST segment elevation diminishes and T wave inverted.
- occurs around 1 week
 ECG CHANGES IN STEMI
5.RESOLUTION OF ST ELEVATION & T WAVE INVERSION - CHRONIC PHASE
- persistent Q wave or reduced /poor R wave
- T wave normalised.
- occurs after months-years
SEQUENCE OF ECG CHANGES IN STEMI
 ST ELEVATION IN ACUTE STEMI
ST elevation in 2 or more contiguous leads of standard
12 lead ECG as follows:
- ≥ 1mm limb leads : I, aVL, II, III, aVF.
- ≥ 1mm precordial leads : V1 & V4 - V6.
- ≥ 2.5mm precordial leads : V2 - V3 . ( males < 40yr )
- ≥ 2.0mm precordial leads : V2 - V3 . ( males ≥ 40yr )
- ≥ 1.5mm precordial leads : V2 - V3 . ( female)
Inferior STEMI

• ST elevation:
II,III,aVF
• Reciprocal ST
depression : I,aVL
• Infarct artery: RCA
(80%)
LCX
(20%)
Anteroseptal STEMI

• ST elevation: V1-V4
• Can have reciprocal
ST depression
inferior leads
• Infarct artery : LAD
Extensive Anterior STEMI

• ST elevation:
I,aVL,V1-V6.
• Can have
reciprocal ST
depression
inferior leads
• Infarct artery :
LAD
Anterior STEMI

• ST elevation: V1-V6.
• Can have reciprocal ST
depression inferior leads
• Infarct artery : LAD
Lateral STEMI

• ST elevation:
I,aVL ,V5-V6.
• Can have
reciprocal ST
depression
inferior leads
• Infarct artery :
LCX
 Posterior infarction
• Usually associated with inferior and/or lateral and or
RV STEMI
• 4% occur alone - called true/isolated posterior STEMI
• ECG of posterior infarction are :

 ST depression ≥ 0.5mm with upright T wave precordial leads : V1 - V4*

and / or
 ST elevation ≥ 0.5mm in the posterior leads : V7 - V9*

*ST changes ≥ 0.1mm in male < 40yr

 True posterior STEMI

 ST depression ≥ 0.5mm with upright T wave precordial leads : V1 – V3

 If we flip or view ECG
posteriorly

 ST depression ≥ 0.5mm with upright T wave precordial leads :V1 – V3

 ST elevation when view ECG posteriorly
 ST depression ≥ 0.5mm in leads : V1-V3  ST elevation ≥ 0.5mm in leads : V7-V9
Other posterior leads placement….

LEAD V1 → LEAD V7
LEAD V2 → LEAD V8
LEAD V3 → LEAD V9
 TRUE POSTERIOR INFARCTION
• ST depression + upright T: V1-V4
and/or
• ST elevation : V7-V9

• Infarct artery : LCX

POSTERIOR LEADS
 Infero - lateral - posterior STEMI
• ST elevation : II,III,aVF
V4-V6
• ST depression: V1-V3
• Infarct artery : RCA

 ST depression ≥ 0.5mm with upright

T wave V1 – V2
 ST elevation ≥ 1mm II,III,aVF &V4-V6
 RV INFARCTION
• Usually with inferior STEMI & ST elevation is
transient, disappearing in less than 10 hours
following its onset in half of patients.
• Do right sided ECG in all inferior STEMI
• ECG of RV infarction is

 ST elevation ≥ 1mm in right sided precordial leads : V3R , V4R.

Do right sided ECG
RV INFARCTION

• ST elevation : RV3 ,RV4

• Usually asstd : inferior
STEMI
• Infarct artery : RCA
 LBBB AND STEMI
• New onset LBBB - as STEMI presentation
• STEMI AS LBBB - higher hospital mortality
• Guidelines  new LBBB  STEMI  reperfusion RX
• Beside STEMI  many other causes of LBBB
• LBBB obscure classical STEMI ECG-Q wave & ST-T changes

• How do we predict the likelihood of LBBB as true STEMI
( the best & goal standard is coronary angiogram !!)
 

BUT…. PCI NOT READILY AVAILABLE ?? ENSURE GIVE FIBRINOLYSIS

EVERYWHERE & WITHIN TIME TO “TRUE “ STEMI…
 LBBB IN STEMI
LBBB can be associated with CAUSES OF LBBB
STEMI in the following ways - STEMI
• True STEMI - with massive
- HYPERTENSION
myocardial damage
• Preexisting LBBB with acute - AORTIC VALVE DISEASE
STEMI - EXTENSIVE CAD
• Transient ischemic LBBB during - DEGENERATIVE DISEASE
STEMI
• Rate dependent LBBB (Usually
- CONGENITAL HEART
tachycardia related ) DISEASE
• STEMI in pacemaker rhythms - PACEMAKER RHYTHM
So we analyse with ….

SGARBOSSA
CRITERIA
 SGARBOSSA CRITERIA
CRITERIA 1:
ST ELEVATION > 1MM IN ANY CONCORDANT
LEAD ( POSITIVE QRS)
SCORE : 5 - MOST PREDICTIVE

CRITERIA 2:
ST DEPRESSION > 1MM IN ANY LEAD V1-V3
SCORE : 3

CRITERIA 3:
ST ELEVATION > 5MM IN ANY DISCORDANT
LEAD ( NEGATIVE QRS)
SCORE : 2 - LEAST PREDICTIVE

SCORE ≥ 3 : 90% SPECIFIC FOR STEMI & CUTPOINT USED

 LBBB + INFERIOR STEMI

LBBB + ST > 1mm in lead with a positive QRS complex ( lead II) → score 5
likely STEMI as score ≥ 3
 LBBB + ANTERIOR MI

LBBB + ST elevation > 1mm in leads with positive QRS complex ( V4-V5)→ score 5
likely STEMI as score ≥ 3
 LBBB

LBBB + ST elevation > 5mm in leads with negative QRS complex (V1-V3) → score 2
 unlikely STEMI as score < 3
LBBB AND PROBABILITY OF STEMI
 CLINICAL ASSESSMENT OF SUCCESSFUL
REPERFUSION

 RESOLUTION OF CHEST PAIN

 ABSOLUTE RESOLUTION OF ST ELEVATION OR

REDUCTION OF ≥ 50% OF ST ELEVATION

 EARLY PEAK CARDIAC ENZYME

 IDIOVENTRICULAR RHYTHM

 T WAVE INVERSION WITHIN 4 HOURS

CLINICAL ASSESSMENT OF SUCCESSFUL
REPERFUSION

PRE REPERFUSION RX POST REPERFUSION RX-90 MIN

Correlation location of STEMI & clinical outcome
EXERCISE 4-ECG IN STEMI
 BENIGN EARLY REPOLARISATION (BER)

• Widespread concave ST elevation, most prominent in the mid- to left precordial leads (V2-5).
• Notching or slurring at the J-point.
• Prominent, slightly asymmetrical T-waves that are concordant with the QRS complexes
(pointing in the same direction).
• The degree of ST elevation is modest in comparison to the T-wave amplitude
(less than 25% of the T wave height in V6)
• ST elevation is usually < 2mm in the precordial leads and < 0.5mm in the limb leads, although
precordial STE may be up to 5mm in some instances.
• No reciprocal ST depression to suggest STEMI (except in aVR).
• ST changes are relatively stable over time (no progression on serial ECG tracings)

CLINICAL FEATURES & ECHO ARE HELPFUL

 PERICARDITIS

• Widespread concave STE and PR depression (I, II, III, aVF, V4-6).
• Reciprocal ST depression and PR elevation in V1 and aVR.

CLINICAL FEATURES & ECHO ARE HELPFUL

 LEFT VENTRICULAR ANEURYSM

Factors favouring left ventricular aneurysm

• ECG identical to previous ECGs (if available).
• Absence of dynamic ST segment changes.
• Absence of reciprocal ST depression.
• Well-formed Q waves.

CLINICAL FEATURES & ECHO ARE HELPFUL

 BRUGADA SYNDROME

CLINICAL FEATURES & ECHO ARE HELPFUL

This ECG abnormality must be associated with one of the following clinical criteria to make
the diagnosis:
• Documented ventricular fibrillation (VF) or polymorphic ventricular tachycardia (VT).
• Family history of sudden cardiac death at <45 years old .
• Coved-type ECGs in family members.
• Inducibility of VT with programmed electrical stimulation .
• Syncope.
• Nocturnal agonal respiration.