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ECG in ACS
Case based
Dr. N.Praveen
MD,DM
52 / M with chest pain. The ECG shows
A. Early repolarization variant B. Pericarditis
C. NSTEMI D. Inferior wall MI
• D. Evolving Inferior wall MI
reciprocal ST depression occurred more frequently in aVL
than in any other lead.
It seems that ST depression in aVL, by contrast to that in the
precordial leads, is found in the majority of patients with
evolving inferior wall myocardial infarction and is not
influenced by extension of the infarction to the right ventricle
or to the posterior wall.
51 /F with chest pain 2 days prior to this tracing. Now pain free, what is the plan ?
A. Discharge and medical management with antiplatelets ,statins
B. Thrombolyse
C. Close monitoring in ICCU D. Should undergo Primary PCI
Answer
• C.close monitoring in ICCU
• Wellen’s syndrome Type I or pattern B
44 /M , F/H/O CAD, recently underwent PTCA + stent to RCA, now
admitted with Typical angina. Admission Trop I is 0.01. Does the patient
have signs of ischemia in ECG? A. Yes B. No
Yes
After giving nikoran infusion and optimizing the antianginals
before discharge
ECGs in Acute Coronary Syndrome
46 M, diabetic, had epigastric pain in afternoon at his work. Taken
antacid. At ER after two hours with mild pain this was the ECG.
A. Rate related ST-T changes.
B. ECG with significant ST-T changes,
needs early reperfusion
C. Severe mitral regurgitation
D. Atrial tachycardia
• B. ECG with ST-T changes needs early reperfusion
Furthermore, the magnitude of ST segment elevation in lead
aVR greater than or equal to that of ST-segment elevation in
lead V1 was found to have 81% sensitivity and 80%
specificity for differentiating acute LMT occlusion from acute
LAD occlusion.
43 M was diagnosed with lateral subendocardial ischemia based
on ST depression in AVL. Do you agree ?
A. Yes B.No
It is an inferior wall STEMI
A 46 /M, sm+,daily worker had left side chest pain in the night, muscle
cramps. The pain subsided after few minutes. The next day he walked into
ER. This is the ECG, what is the next plan.
A. Check calcium B. Do MRI Brain (cerebral T waves)
C. Admit the patient in ICCU. D.Old Anterior wall MI needs MMx
Wellen’s syndrome Type II (or Pattern A)
American Heart Journal103;730. 1982
Of 145 patients consecutively admitted because of unstable angina, 26
(16%) showing this ECG pattern, suggesting that this finding is not rare.
In spite of symptom control by nltroglycerln and beta blockade,
12 of 16 patients (75%) who were not operated on developed a usually
extensive anterior wall infarction within a few weeks after admission.
50 /M ,poorly controlled chronic diabetic had atypical chest pain.
This is the ECG at PHC what is the next plan?
A.Give loading dose of antiplatelets,thrombolyse
B.Junctional rhythm,needs pacemaker support
C.Rule out hyperkalemia
D.Evolved AWMI, give antiplatelets,statins
De Winter T waves
• STEMI equivalent
• Seen in 2% patients with AWMI
• should receive reperfusion therapy PCI or Thrombolysis
Instead of the signature ST-segment elevation, the ST segment showed a 1- to 3-mm
upsloping ST-segment depression at the J point in leads V1 to V6 that continued into
tall, positive symmetrical T waves. The QRS complexes were usually not widened or
were only slightly widened, and in some there was a loss of precordial R-wave
progression. In most patients there was a 1- to 2-mm ST-elevation in lead aVR.
We recognized this characteristic ECG pattern in 30 of 1532 patients with anterior
myocardial infarction (2.0%).
Robbert J. de Winter, M.D., Ph.D.,Niels J.W. Verouden, M.D.
Hein J.J. Wellens, M.D., Ph.D.,Arthur A.M. Wilde, M.D., Ph.D.
1100 DD Amsterdam, the Netherlands
N Engl J Med 359;19 November 6, 2008 2071
ECGs in Acute Coronary Syndrome
A 56 F, washer woman DM, HTN, Hypothyroidism. Had left upper limb pain on
daily work since 15 days. Echo was normal. This is the ECG ?
A.Normal ECG give analgesics B. Observe for 24 hours send troponin
C.Do treadmill test ,CAG. D. Check electrolytes
Answer
• Do treadmill test
• CAG
• Fragmented QRS complexes in inferior leads
Fragmented QRS is defined as the presence of R’ wave or notching
of R or S wave in the presence of narrow QRS. It indicates
heterogeneous depolarization of the ventricular myocardium that
can occur due to ischemia, fibrosis, or scar. It may also be a
marker of coronary microvascular dysfunction. In the context of
epicardial coronary artery disease, it is associated with multivessel
disease and greater incidence of cardiac events.
A 70 year male no risk factors, H/O GERD, had left side chest pain for few
minutes, mild sweating. Relieved by belchings. Next day morning, he came to
ER. He was not having chest pain. What is the plan
A. Do treadmill test for ischemia
B. Loading doses of antiplatelets, statins, CAG- PTCA
C. GI Endoscopy
D. Do viability imaging
• B. Wellen’s syndrome type A
• Had critical lesion in proximal LAD
• PTCA +Stent to LAD done
• asymptomatic
ECGs in Acute Coronary Syndrome
A 54 /M, Severe AR admitted with rest angina.
Does he needs Evalaution for CAD A. Yes B.No
Inverted U waves in lateral leads are suggestive of ischemia
Sovari AA, Farokhi F, Kocheril AG.
Inverted U wave, a specific electrocardiographic sign of cardiac
ischemia. Am J Emerg Med. 2007 Feb;25(2):235 -7
Correale E.
The negative U wave: a pathogenetic enigma but a useful, often
overlooked bedside diagnostic and prognostic clue in ischemic
heart disease. Clin Cardiol 2004;27(12):674 - 7.
65 f shortness of breath class II since 15 days.Class III since 2 days.
Diabetic ,Hypertensive
A.Rate related ST-T depression, T wave inversions
B.NSTEMI C Evolved AWMI D. Stable angina
• B.NSTEMI
57 M, f/h/o CAD, DOE since 10 days .He was stabilized.
A.Do angiography B. Treadmill Test
C. Viability test D. Dobutamine stress echo
• A. Do angiography
ST depression (especially horizontal or downsloping) is highly
suggestive of NSTE-ACS .
Marked symmetrical precordial T-wave inversion (≥2 mm [0.2 mV])
suggests acute ischemia, particularly due to a critical stenosis of
the left anterior descending coronary artery; it may also be seen
with Acute PE and right sided ST-T changes.
2014 ACC –AHA NSTEMI guidelines
ECGs in Acute Coronary Syndrome
To be read article
Some of the ECGs
• www.ecg-maven.com
• All variety of ECGS for assessment with various
levels of grading
• www.lifeinthefastlane.com
Take home message
 1.Whenever in doubt of ST elevation in inferior leads ,look at lead
AVL – ST depression, T inversion – tell tale sign of ischemia.
 2. Anterior precordial leads – Biphasic T inversions, Deep T wave
inversions – no angina – needs evaluation as AWMI.
 3.Anterior precordial leads – J point depression ,Tall T waves – needs
evaluation as STEMI
 4.ST elevation in AVR to be kept in mind,whenever there are ST
depressions in multiple leads.
 5.Inverted U waves in a patient with AR, chronic HTN – suggestive of
ischemia.
Thank you

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ECGs in Acute Coronary Syndrome

  • 1. ECG in ACS Case based Dr. N.Praveen MD,DM
  • 2. 52 / M with chest pain. The ECG shows A. Early repolarization variant B. Pericarditis C. NSTEMI D. Inferior wall MI
  • 3. • D. Evolving Inferior wall MI
  • 4. reciprocal ST depression occurred more frequently in aVL than in any other lead. It seems that ST depression in aVL, by contrast to that in the precordial leads, is found in the majority of patients with evolving inferior wall myocardial infarction and is not influenced by extension of the infarction to the right ventricle or to the posterior wall.
  • 5. 51 /F with chest pain 2 days prior to this tracing. Now pain free, what is the plan ? A. Discharge and medical management with antiplatelets ,statins B. Thrombolyse C. Close monitoring in ICCU D. Should undergo Primary PCI
  • 6. Answer • C.close monitoring in ICCU • Wellen’s syndrome Type I or pattern B
  • 7. 44 /M , F/H/O CAD, recently underwent PTCA + stent to RCA, now admitted with Typical angina. Admission Trop I is 0.01. Does the patient have signs of ischemia in ECG? A. Yes B. No
  • 8. Yes
  • 9. After giving nikoran infusion and optimizing the antianginals before discharge
  • 11. 46 M, diabetic, had epigastric pain in afternoon at his work. Taken antacid. At ER after two hours with mild pain this was the ECG. A. Rate related ST-T changes. B. ECG with significant ST-T changes, needs early reperfusion C. Severe mitral regurgitation D. Atrial tachycardia
  • 12. • B. ECG with ST-T changes needs early reperfusion
  • 13. Furthermore, the magnitude of ST segment elevation in lead aVR greater than or equal to that of ST-segment elevation in lead V1 was found to have 81% sensitivity and 80% specificity for differentiating acute LMT occlusion from acute LAD occlusion.
  • 14. 43 M was diagnosed with lateral subendocardial ischemia based on ST depression in AVL. Do you agree ? A. Yes B.No
  • 15. It is an inferior wall STEMI
  • 16. A 46 /M, sm+,daily worker had left side chest pain in the night, muscle cramps. The pain subsided after few minutes. The next day he walked into ER. This is the ECG, what is the next plan. A. Check calcium B. Do MRI Brain (cerebral T waves) C. Admit the patient in ICCU. D.Old Anterior wall MI needs MMx
  • 17. Wellen’s syndrome Type II (or Pattern A)
  • 18. American Heart Journal103;730. 1982 Of 145 patients consecutively admitted because of unstable angina, 26 (16%) showing this ECG pattern, suggesting that this finding is not rare. In spite of symptom control by nltroglycerln and beta blockade, 12 of 16 patients (75%) who were not operated on developed a usually extensive anterior wall infarction within a few weeks after admission.
  • 19. 50 /M ,poorly controlled chronic diabetic had atypical chest pain. This is the ECG at PHC what is the next plan? A.Give loading dose of antiplatelets,thrombolyse B.Junctional rhythm,needs pacemaker support C.Rule out hyperkalemia D.Evolved AWMI, give antiplatelets,statins
  • 20. De Winter T waves • STEMI equivalent • Seen in 2% patients with AWMI • should receive reperfusion therapy PCI or Thrombolysis
  • 21. Instead of the signature ST-segment elevation, the ST segment showed a 1- to 3-mm upsloping ST-segment depression at the J point in leads V1 to V6 that continued into tall, positive symmetrical T waves. The QRS complexes were usually not widened or were only slightly widened, and in some there was a loss of precordial R-wave progression. In most patients there was a 1- to 2-mm ST-elevation in lead aVR. We recognized this characteristic ECG pattern in 30 of 1532 patients with anterior myocardial infarction (2.0%). Robbert J. de Winter, M.D., Ph.D.,Niels J.W. Verouden, M.D. Hein J.J. Wellens, M.D., Ph.D.,Arthur A.M. Wilde, M.D., Ph.D. 1100 DD Amsterdam, the Netherlands N Engl J Med 359;19 November 6, 2008 2071
  • 23. A 56 F, washer woman DM, HTN, Hypothyroidism. Had left upper limb pain on daily work since 15 days. Echo was normal. This is the ECG ? A.Normal ECG give analgesics B. Observe for 24 hours send troponin C.Do treadmill test ,CAG. D. Check electrolytes
  • 24. Answer • Do treadmill test • CAG • Fragmented QRS complexes in inferior leads
  • 25. Fragmented QRS is defined as the presence of R’ wave or notching of R or S wave in the presence of narrow QRS. It indicates heterogeneous depolarization of the ventricular myocardium that can occur due to ischemia, fibrosis, or scar. It may also be a marker of coronary microvascular dysfunction. In the context of epicardial coronary artery disease, it is associated with multivessel disease and greater incidence of cardiac events.
  • 26. A 70 year male no risk factors, H/O GERD, had left side chest pain for few minutes, mild sweating. Relieved by belchings. Next day morning, he came to ER. He was not having chest pain. What is the plan A. Do treadmill test for ischemia B. Loading doses of antiplatelets, statins, CAG- PTCA C. GI Endoscopy D. Do viability imaging
  • 27. • B. Wellen’s syndrome type A • Had critical lesion in proximal LAD • PTCA +Stent to LAD done • asymptomatic
  • 29. A 54 /M, Severe AR admitted with rest angina. Does he needs Evalaution for CAD A. Yes B.No
  • 30. Inverted U waves in lateral leads are suggestive of ischemia
  • 31. Sovari AA, Farokhi F, Kocheril AG. Inverted U wave, a specific electrocardiographic sign of cardiac ischemia. Am J Emerg Med. 2007 Feb;25(2):235 -7 Correale E. The negative U wave: a pathogenetic enigma but a useful, often overlooked bedside diagnostic and prognostic clue in ischemic heart disease. Clin Cardiol 2004;27(12):674 - 7.
  • 32. 65 f shortness of breath class II since 15 days.Class III since 2 days. Diabetic ,Hypertensive A.Rate related ST-T depression, T wave inversions B.NSTEMI C Evolved AWMI D. Stable angina
  • 34. 57 M, f/h/o CAD, DOE since 10 days .He was stabilized. A.Do angiography B. Treadmill Test C. Viability test D. Dobutamine stress echo
  • 35. • A. Do angiography ST depression (especially horizontal or downsloping) is highly suggestive of NSTE-ACS . Marked symmetrical precordial T-wave inversion (≥2 mm [0.2 mV]) suggests acute ischemia, particularly due to a critical stenosis of the left anterior descending coronary artery; it may also be seen with Acute PE and right sided ST-T changes. 2014 ACC –AHA NSTEMI guidelines
  • 37. To be read article
  • 38. Some of the ECGs • www.ecg-maven.com • All variety of ECGS for assessment with various levels of grading • www.lifeinthefastlane.com
  • 39. Take home message  1.Whenever in doubt of ST elevation in inferior leads ,look at lead AVL – ST depression, T inversion – tell tale sign of ischemia.  2. Anterior precordial leads – Biphasic T inversions, Deep T wave inversions – no angina – needs evaluation as AWMI.  3.Anterior precordial leads – J point depression ,Tall T waves – needs evaluation as STEMI  4.ST elevation in AVR to be kept in mind,whenever there are ST depressions in multiple leads.  5.Inverted U waves in a patient with AR, chronic HTN – suggestive of ischemia.

Notes de l'éditeur

  1. Evolving Inferior wall MI Slight inferior ST elevation with T wave inversion. Also minimal ST depression in lead AVL. Relatively low limb lead voltages makes these findings more subtle.