Classic, Confusing, and Confounding Patterns - umem.org · Classic, Confusing, and Confounding...

Cardiac Ischemia ECG Workshop

Classic, Confusing, and Confounding Patterns

Amal Mattu, MD, NE

Professor and Vice Chair

Department of Emergency Medicine

University of Maryland School of Medicine

[email protected]

A Few Points To Start…

• Advanced content…


• Advanced content…

Courtesy Heidi Farinholt, MD


• Workshop

– Questions? [email protected]

• Writing

• Handout/PDF

– Lectures.umem.org/SEMA

– Lectures will be posted for 1 month

Why is this important?


• ACS is high-risk but high payoff!

– Very good outcome vs. very bad outcome


• ACS is high-risk but high payoff!

– Very good outcome vs. very bad outcome

• Missed ACS 25-35% mortality

– In elderly 50% 3-day mortality


• Missed ACS accounts for 20% of malpractice dollars paid out in EM

• > 25% of cases involve ECG misreads


• Missed ACS accounts for 20% of malpractice dollars paid out in EM

• > 25% of cases involve ECG misreads

• My experience: > 50% involve ECG misreads that are not “arguable”

Some basics…

Acute Myocardial Infarction/Ischemia

• ECG changes

– Completely normal ECG in up to 6% of acute MIs

– Subendocardial MI (NQWMI, NSTEMI) associated with ST- and T-wave abnls.


• ECG changes

– ST elevation injury pattern

– Q-waves infarcted tissue

• Develop within hours

• “Significant” Q-waves


• ECG changes

– ST depression ischemia or infarction

• High morbidity and mortality if untreated

– T-wave inversions ischemia

• Lower specificity and morbidity

Acute Myocardial Infarction

• ECG changes

– Anterior MI

• usually associated with LAD occlusion

• STE in leads V1-V6


• ECG changes

– Septal MI

• STE limited to leads V1-V2

– Anteroseptal MI

• STE in leads V1-V4

– Anterolateral MI

• STE in leads V3-V6, I, and aVL


• ECG changes

– Inferior MI

• usually RCA occlusion

• STE in II, III, aVF

• reciprocal changes most common in aVL

• always consider possibility of posterior and/or right ventricular involvement

I

II III aVF

aVL aVR


• ECG changes

– Lateral MI

• usually left circumflex occlusion

• STE in leads I, aVL, V5-V6

• remember that leads I and aVL are both lateral contiguous leads

– even though they are not next to each other on the ECG

– isolated STE I and aVL ”high lateral MI”

I

II III aVF

aVL aVR

STE in I and aVL, “high lateral STEMI”


• “Use of the ECG in AMI” (NEJM 2003)

– Resolution of STE marker reperfusion

– Absence of STE resolution within 90 minutes consider rescue PCI

– If reperfusion occurs, STE should resolve by at least 75% (in the lead with maximum STE)


• “Use of the ECG in AMI” (NEJM 2003)

– T-wave inversion within 4 hours is highly specific for reperfusion

• if occurs after 4 hours, uncertain reperfusion

– [another marker that is highly specific of reperfusion AIVR]

Accelerated Idioventricular Rhythm (AIVR)

#1: 81 yo woman with SOB, orthopnea, and edema

#1: LBBB with AMI


• Who gets acute reperfusion therapy for presumed STEMI?



– Concerning symptoms AND

– ECG:

• 1 mm STE in contiguous leads OR

• Posterior STEMI OR

• Presumed new LBBB OR

• LBBB with Sgarbossa criteria OR

• [Pacemaker with Sgarbossa criteria]



– Concerning symptoms AND

– ECG:

• 1 mm STE in contiguous leads OR

• Posterior STEMI OR

• Presumed new LBBB OR [ACC/AHA 2013]

• LBBB with Sgarbossa criteria OR

• [Pacemaker with Sgarbossa criteria]

Neeland, et al. JACC 2012

New LBBB and AMI

Normal LBBB

Rule of appropriate discordance

(true for pacemakers also)

Concordance / Discordance QRS complex - ST segment / T wave

• Discordance -- major, terminal

portion of QRS complex (“A”) &

ST segment / T wave (“B”) --

opposite sides of baseline

• Normal vs. abnormal

– “Excessive” discordant elevation

A

A

B

B

Courtesy Bill Brady, MD


• Concordance -- major,

terminal portion of QRS

complex (“A”) & ST

segment / T wave (“B”) -- same

side of baseline

• Abnormal – Concordant elevation (upper)

– Concordant depression (lower)

A

B

A

B


• Discordance

A. Normal: < 5mm

B. Potentially

abnormal: > 5mm


A

B


Left Bundle Branch Block Diagnosis of AMI -- Sgarbossa criteria

A B C

A -- Concordant ST elevation > 1 mm in any lead

B -- Concordant ST depression > 1 mm in V1, V2, or V3

C -- Discordant ST elevation > 5 mm (less specific)

Criteria are very specific though have low sensitivity.


#1: LBBB with AMI

LBBB with AMI


LBBB with AMI

Courtesy Dr. Nicolas Pineda

85 yo woman with CP Courtesy Dr. Eric Klotz

Rapid Afib (147) and LBBB with AMI

Normal (AV Sequential) Pacemaker

Pacemaker with AMI

38 yo woman with chest pain

Courtesy Jim Campagna, MD

Baseline ECG


38 yo woman with chest pain


90 yo man with CP

Courtesy Nicolina Andersson, MD

76 yo man with decr. LOC + hypotension

Courtesy Dr. Santiago Harris

Handy Scanner for Android

Uncomplicated RBBB

RBBB with acute antero-lat MI (old inferior MI)

RBBB with acute antero-lateral MI

#2: 58 yo man with CP and SOB at home, now asymp.

#2: Wellens’ Syndrome

• De Zwann C, Bar FW, Wellens HJJ (Am Heart J, 1982)

– Pattern of ECG T-wave abnormality in mid-precordial leads (V2-V3, + V4)

– Highly specific for critical obstruction in proximal LAD

– High risk for extensive anterior MI, death

– 2 patterns…

Wellens’ Syndrome

V2 V3

Deep TWIs Biphasic

Wellens’ Syndrome

• Warnings…

– Type 2 pattern often misdiagnosed as “non-specific T-wave pattern” or “normal”

– ST changes are often absent

– ECG abnormality usually present in pain-free state

– Cardiac biomarkers often normal initially

Wellens’ Syndrome

• Warnings…

– Patients are best evaluated and managed with catheterization/PCI

• Stress testing may precipitate AMI

• Medical management usually ineffective for proximal LAD lesions

• Natural history: anterior wall MI unless early PCI

– Wellens: 75% of patients developed AMI within weeks if medically managed

Wellens’ Syndrome

Wellens’ Syndrome

24 yo man with lupus presenting with chest pain

…4 DAYS LATER

49 yo man with chest pain …

49 yo man with chest pain (recent negative stress test)

Baseline ECG

Pain worsening later in day ………………..…..

Pain worsening later in day Cath (90% LAD)

40 yo intoxicated man with chest pain

Dx GERD, but worsening symtpoms serial ECGs

Wellens’ Sign

Sent to cath lab 95% LAD

48 yo man with 2/10 chest pain (#1)

48 yo man with 2/10 chest pain (#2)

100% LAD lesion, 4v CABG

Wellens’ Sign

Computer: Old inferior MI, PRWP, NS-Ts

100% LAD occlusion

Pain-Free Courtesy Jason Mansour, MD

Baseline

Courtesy Jason Mansour, MD

One hour later CP returns…


Cath 90% LAD Occlusion


58 yo man with resolved CP, cardiol/machine: “NS-Ts”

…later developed stuttering CP, TN 10

#3: 31 yo man with atypical chest pain

STE, “normal variant” (with high voltage)

Wang, et al. ST-segment elevation in conditions other than acute myocardial infarction. N Engl J Med 2003;349:2128-2135.

STE concave upwards before drop

38 yo man with chest pain, 95% LAD lesion

Courtesy Chuck Sheppard, MD

18 yo male with chest pain after amphetamines

Courtesy Katie Baugher, DO

Admitted, ruled-out for MI

Courtesy Katie Baugher, DO

Admitted, ruled-out for MI

#4: 49 yo man with vomiting and diarrhea for 3 days

#4: Severe Hypokalemia

Severe Hypokalemia

Digoxin Toxicity With Hypokalemia

Severe Hypokalemia (1.8)

Severe Hypokalemia (2.5)

K+ = 2.0 mmol/L

Courtesy Dr. Prathibha Shenoy

K+ = 1.2 mmol/L Courtesy Dr. Osama Muhammad Ali

#5: 43 yo woman with chest pain and diaphoresis

#5: Isolated PMI

Anteroseptal ischemia?

• ST depression in anteroseptal leads

– Anteroseptal ischemia

– Posterior STEMI

– Miscellaneous

• RBBB

• Hypokalemia

• Etc.

Posterior Myocardial Infarction

• ECG changes

– Usually associated with inferior MI due to RCA or circumflex occlusion

– 4% of STEMIs are isolated PMIs

– Increased M&M compared to isolated IMI

– Mirror image of septal MI in leads V1-V3 • large R-waves (instead of Qs)

• STD (instead of STE)

• upright T-waves (instead of inversions)


Septal MI STE Inverted Ts

Qs develop over hours

Posterior MI

ECG Changes in Leads V1-V3


Septal MI STE Inverted Ts

Qs develop over hours

Posterior MI

STD Upright Ts Tall Rs develop over hours

ECG Changes in Leads V1-V3

Inferior-posterior MI

Inferior-posterior MI (after 2 hours)

43 yo woman with chest pain and diaphoresis

Isolated PMI

Isolated PMI — Posterior Leads

Anteroseptal ischemia…??

Isolated PMI!

Early PLMI — Posterior Leads (V3-V6)

Early PMI

Computer: “Possible anterior subendocardial injury”

PMI: V1-5 wrapped around left mid-back

78 yo man with syncope Courtesy Dr. Amitava Mukhopadhyay

• 15 minutes after arrival VTach

Case Courtesy Dr. Amitava Mukhopadhyay

http://simpsonspedia.net/index.php?title=Bild:9F09.jpg

• 15 minutes after arrival VTach

• Then cardiac arrest


• Resuscitation attempts successful

• Went to cath lab


• Resuscitation attempts successful

• Went to cath lab successful PCI

– 100% RCA, 50% left Cx lesions


Classic, Confusing, and Confounding Patterns - umem.org · Classic, Confusing, and Confounding...

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