STEMI equivalents: Difference between revisions

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==Background==
==Background==
*Standard teaching for STEMI typically has the following criteria<ref>ECC Committee, Subcommittees and Task Forces of the American Heart Association.. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care — Part 8: Stabilization of the Patient With Acute Coronary Syndromes. Circulation. 2005. 112 (24_suppl):IV–89–IV–110. 2005.</ref>
*STEMI typically defined by<ref>ECC Committee, Subcommittees and Task Forces of the American Heart Association.. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care — Part 8: Stabilization of the Patient With Acute Coronary Syndromes. Circulation. 2005. 112 (24_suppl):IV–89–IV–110. 2005.</ref>:
**≥1 mm (0.1 mV) of ST segment elevation in the limb leads
**≥1 mm (0.1 mV) ST segment elevation in limb leads
**≥ 2 mm elevation in the precordial leads and present in anatomically contiguous leads
**≥ 2 mm ST segment elevation in precordial leads
*There are several variations from the classic STEMI ECG changes that do not fit this definition
**Findings present in at least 2 anatomically contiguous leads
*Several variations from the classic STEMI ECG changes are similarly concerning and considered 'STEMI equivalent'


==STEMI Equivalents==
==STEMI Equivalents==
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*RCA (90%), LCA (10%)
*RCA (90%), LCA (10%)
*12-Lead ECG findings<ref>Van Gorselen EO, et al. Posterior myocardial infarction: the dark side of the moon. Neth Heart J. 2007; 15:16-21.</ref>
*12-Lead ECG findings<ref>Van Gorselen EO, et al. Posterior myocardial infarction: the dark side of the moon. Neth Heart J. 2007; 15:16-21.</ref>
**ST-segment depression (horizontal >> downsloping/upsloping
**ST-segment depression (horizontal >> downsloping/upsloping)
**Prominent and broad R wave (>30ms)
**Prominent and broad R wave (>30ms)
**Relative tall R waves in precordial leads (may find R = S amplitude in V1)
**R/S wave ratio >1.0 in lead V2
**R/S wave ratio >1.0 in lead V2
**Prominent, upright T wave
**Prominent, upright T wave
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**V9: Left paraspinal area line along the 5th ICS
**V9: Left paraspinal area line along the 5th ICS
*Posterior ECG findings
*Posterior ECG findings
**≥1 mm ST-segment elevation
**≥0.5 mm ST-segment elevation
[[File:Posterior MI.jpg|px300]]
[[File:Posterior MI.jpg|350px]]


===LMCA Occlusion===
===LMCA Occlusion===
*Seen with occlusion or near-occlusion of the left main artery<ref>Hennings JR and Fesmire FM. A new electrocardiographic criteria for emergent reperfusion therapy. Am J Emerg Med. 2012; 30(6):994–1000.</ref>
*Seen with left main artery lesion<ref>Hennings JR and Fesmire FM. A new electrocardiographic criteria for emergent reperfusion therapy. Am J Emerg Med. 2012; 30(6):994–1000.</ref>
*Has been reported in occlusion of the proximal left anterior descending artery and severe multivessel coronary artery disease
*Also reported in proximal LAD lesions and severe multivessel coronary artery disease
*12-Lead ECG findings
*12-Lead ECG findings
**ST elevation in aVR ≥ 1mm
**ST elevation in aVR ≥ 1mm
**ST elevation in aVR ≥ V1
**ST elevation in aVR ≥ V1
**ST depression typically seen in lateral leads
**ST depression typically seen in lateral  
[[File:AVR.jpg|350px]]


===[[De Winter’s T Waves]]===
===[[De Winter’s T Waves]]===
*Suggestive of proximal LAD lesion
*Suggests proximal LAD lesion
*12-Lead ECG findings<ref>de Winter R, et al. A new ECG sign of proximal LAD occlusion. NEJM. 2008; 359:2071–2073.</ref>
*12-Lead ECG findings<ref>de Winter R, et al. A new ECG sign of proximal LAD occlusion. NEJM. 2008; 359:2071–2073.</ref>
**Precordial ST-segment depression at the J-point
**Precordial ST-segment depression at the J-point
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**ST elevation ≥5 mm in a lead with downward (discordant) QRS complex - 2 points
**ST elevation ≥5 mm in a lead with downward (discordant) QRS complex - 2 points
*Smith's modification<ref>Smith, S, et al. 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 Sgarbossa Rule. 60(6):766-776.</ref>
*Smith's modification<ref>Smith, S, et al. 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 Sgarbossa Rule. 60(6):766-776.</ref>
**Changes the 3rd rule of original Sgarbossa's Criteria to be ST depression OR elevation discordant w/ the QRS complex and w/ a magnitude of at least 25% of the QRS increases Sn from 52% to 91% at the expense of reducing Sp from 98% to 90%[
**Changes the 3rd rule of original Sgarbossa's Criteria to be ST depression '''OR''' elevation discordant with the QRS complex and with a magnitude of at least 25% of the QRS increases Sn from 52% to 91% at the expense of reducing Sp from 98% to 90%[
[[File:Sgarbossa.jpg|350px]]
[[File:Sgarbossa.jpg|350px]]


===[[Wellens’ Syndrome]]===
===[[Wellens’ Syndrome]]===
*ECG findings in absence of chest pain, but with recent cardiac chest pain symptoms
*[[ECG]] findings in absence of chest pain, but with recent cardiac chest pain symptoms
*Represents critical stenosis of the LAD
*Represents critical stenosis of the LAD
*Not necessarily STEMI equivalent but will require PCI in the next 24-48hr
*Requires PCI in the next 24-48hr (may evolve more rapidly - observe with serial ECGs)
*12-Lead ECG findings<ref>Rhinehardt J, et al. Electrocardiographic manifestations of Wellens' syndrome. Am J Emerg Med. 2002; 20(7):638-43.</ref>
*12-Lead ECG findings<ref>Rhinehardt J, et al. Electrocardiographic manifestations of Wellens' syndrome. Am J Emerg Med. 2002; 20(7):638-43.</ref>
**Deeply-inverted or biphasic T waves in V2-3
**Deeply-inverted or biphasic T waves in V2-3
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**Absent precordial Q waves with preserved R waves
**Absent precordial Q waves with preserved R waves
*Two T wave characteristics:
*Two T wave characteristics:
**Type A: Inversion pattern - 75% - Deeply inverted and symmetric T-waves
**Type A: Biphasic pattern - 25% - Biphasic T-waves
**Type B: Biphasic pattern - 25% - Biphasic T-waves (initial + deflection and terminal - deflection)
**Type B: Inversion pattern - 75% - Deeply inverted and symmetric T-waves
[[File:Wellens.jpg|350px]]
[[File:Wellens.jpg|350px]]


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===[[LBBB|New LBBB]]===
===[[LBBB|New LBBB]]===
*New LBBB alone is no longer a reason to activate the cath lab<ref>Jain  S, et al. Utility of left bundle branch block as a diagnostic criterion for acute myocardial infarction. Am J Cardiol. 2011; 107:1111-1116.</ref>
*New LBBB alone is no longer a reason to activate the cath lab<ref>Jain  S, et al. Utility of left bundle branch block as a diagnostic criterion for acute myocardial infarction. Am J Cardiol. 2011; 107:1111-1116.</ref>
*However, careful w/u for ACS should be taken for symptomatic patients with LBBB
*However, careful workup for ACS should be taken for symptomatic patients with LBBB
*12-Lead ECG findings
*12-Lead ECG findings
**QRS > 0.12 in limb leads
**QRS > 0.12 in limb leads
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***Large and wide R waves — leads I, aVL, V5, and V6
***Large and wide R waves — leads I, aVL, V5, and V6
***Small R wave followed by deep S wave —leads II, III, aVF, V1–V3
***Small R wave followed by deep S wave —leads II, III, aVF, V1–V3
[[File:LBBB.jpg|350px]]
==External Links==
*[https://www.youtube.com/watch?v=JxPgcPEqI5k Amal Mattu ECG Case: April 29 2012]


==See Also==
==See Also==
*[[ST-Elevation Myocardial Infarction (STEMI)]]
*[[ST-segment elevation myocardial infarction]]
*[[Acute Coronary Syndrome (Main)]]
*[[Acute Coronary Syndrome (Main)]]
*[[Chest pain]]
*[[Chest pain]]
*[[ECG (Main)]]
*[[ECG (Main)]]


==External Links==
==References==
 
==Source ==
<references/>
<references/>


[[Category:Cards]]
[[Category:Cardiology]]

Latest revision as of 19:23, 5 November 2020

Background

  • STEMI typically defined by[1]:
    • ≥1 mm (0.1 mV) ST segment elevation in limb leads
    • ≥ 2 mm ST segment elevation in precordial leads
    • Findings present in at least 2 anatomically contiguous leads
  • Several variations from the classic STEMI ECG changes are similarly concerning and considered 'STEMI equivalent'

STEMI Equivalents

Posterior MI

  • RCA (90%), LCA (10%)
  • 12-Lead ECG findings[2]
    • ST-segment depression (horizontal >> downsloping/upsloping)
    • Prominent and broad R wave (>30ms)
    • Relative tall R waves in precordial leads (may find R = S amplitude in V1)
    • R/S wave ratio >1.0 in lead V2
    • Prominent, upright T wave
    • Combination of horizontal ST-segment depression with upright T wave
  • Posterior ECG or 15-lead ECG may be helpful
    • V7: Left posterior axillary line along the 5th ICS
    • V8: Tip of the left scapula line along the 5th ICS
    • V9: Left paraspinal area line along the 5th ICS
  • Posterior ECG findings
    • ≥0.5 mm ST-segment elevation

Posterior MI.jpg

LMCA Occlusion

  • Seen with left main artery lesion[3]
  • Also reported in proximal LAD lesions and severe multivessel coronary artery disease
  • 12-Lead ECG findings
    • ST elevation in aVR ≥ 1mm
    • ST elevation in aVR ≥ V1
    • ST depression typically seen in lateral

AVR.jpg

De Winter’s T Waves

  • Suggests proximal LAD lesion
  • 12-Lead ECG findings[4]
    • Precordial ST-segment depression at the J-point
    • Tall, peaked, symmetric T waves in the precordial leads
    • Lead aVR shows slight ST-segment elevation in most cases

Dewinter.jpg

Sgarbossa's Criteria

  • Used to identify STEMI in the setting of LBBB or pacemaker
  • Original Criteria[5]
    • ≥3 points = 98% probability of STEMI
    • ST elevation ≥1 mm in a lead with upward (concordant) QRS complex - 5 points
    • ST depression ≥1 mm in lead V1, V2, or V3 - 3 points
    • ST elevation ≥5 mm in a lead with downward (discordant) QRS complex - 2 points
  • Smith's modification[6]
    • Changes the 3rd rule of original Sgarbossa's Criteria to be ST depression OR elevation discordant with the QRS complex and with a magnitude of at least 25% of the QRS increases Sn from 52% to 91% at the expense of reducing Sp from 98% to 90%[

Sgarbossa.jpg

Wellens’ Syndrome

  • ECG findings in absence of chest pain, but with recent cardiac chest pain symptoms
  • Represents critical stenosis of the LAD
  • Requires PCI in the next 24-48hr (may evolve more rapidly - observe with serial ECGs)
  • 12-Lead ECG findings[7]
    • Deeply-inverted or biphasic T waves in V2-3
    • Isoelectric or minimally-elevated ST segment (<1 mm)
    • Absent precordial Q waves with preserved R waves
  • Two T wave characteristics:
    • Type A: Biphasic pattern - 25% - Biphasic T-waves
    • Type B: Inversion pattern - 75% - Deeply inverted and symmetric T-waves

Wellens.jpg

No Longer STEMI Equivalents

New LBBB

  • New LBBB alone is no longer a reason to activate the cath lab[8]
  • However, careful workup for ACS should be taken for symptomatic patients with LBBB
  • 12-Lead ECG findings
    • QRS > 0.12 in limb leads
    • Leads
      • Large and wide R waves — leads I, aVL, V5, and V6
      • Small R wave followed by deep S wave —leads II, III, aVF, V1–V3

LBBB.jpg

External Links

See Also

References

  1. ↑ ECC Committee, Subcommittees and Task Forces of the American Heart Association.. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care — Part 8: Stabilization of the Patient With Acute Coronary Syndromes. Circulation. 2005. 112 (24_suppl):IV–89–IV–110. 2005.
  2. ↑ Van Gorselen EO, et al. Posterior myocardial infarction: the dark side of the moon. Neth Heart J. 2007; 15:16-21.
  3. ↑ Hennings JR and Fesmire FM. A new electrocardiographic criteria for emergent reperfusion therapy. Am J Emerg Med. 2012; 30(6):994–1000.
  4. ↑ de Winter R, et al. A new ECG sign of proximal LAD occlusion. NEJM. 2008; 359:2071–2073.
  5. ↑ Sgarbossa E, et al.. "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". NEJM. 1996; 334(8):481-7.
  6. ↑ Smith, S, et al. 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 Sgarbossa Rule. 60(6):766-776.
  7. ↑ Rhinehardt J, et al. Electrocardiographic manifestations of Wellens' syndrome. Am J Emerg Med. 2002; 20(7):638-43.
  8. ↑ Jain S, et al. Utility of left bundle branch block as a diagnostic criterion for acute myocardial infarction. Am J Cardiol. 2011; 107:1111-1116.
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