Approach to a patient with ST segment abnormality in ECG

Case: A 45 years old presented with chest discomfort and excessive sweating for last 2 hours. He was diabetic, smoker and dyslipidemic. His pulse 68b/min and BP-130/80 mm Hg. In emergency department he had the following ECG.
Case: A 25 years old gentleman presented with chest pain and fever .He was normotensive, non-smoker and non-diabetic. His pulse 128b/min and BP-130/80 mm Hg. Troponin I was normal.
Case: A 54 years old lady presented with chest discomfort and excessive sweating for last 4 hours. She was diabetic, hypertensive and dyslipidemic. Her pulse 62b/min and BP-160/90 mm Hg. In emergency department she had the following ECG.

1. Fundamentals of ECG
Approach to a patient with ST segment
abnormalities in ECG
Dr. Md.ToufiqurRahman
MBBS, FCPS, MD, FACC, FESC, FRCP, FSCAI,
FCCP,FAPSC, FAPSIC, FAHA,FACP
Professor & head of Cardiology
CMMC, Manikganj
Ex professor of cardiology,
NICVD, Dhaka

2. Fundamentals of ECG ST segment

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ST segment
Professor DrMdToufiqurRahman
Fundamentals of ECG
Case: A 45 years old presented with chest discomfort and excessive
sweating for last 2 hours. He was diabetic, smoker and dyslipidemic.
His pulse 68b/min and BP-130/80 mm Hg. In emergency department
he had the following ECG.
Figure: ST segment elevation in V2-V6, Lead 1 and aVLsuggesting (
Extensive anterior wall myocardial infarction) and ST segment
depression in inferior leads (II, III, aVF).

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ST segment
Professor DrMdToufiqurRahman
Fundamentals of ECG
Case: A 25 years old gentleman presented with chest pain and fever
.He was normotensive, non-smoker and non-diabetic. His pulse
128b/min and BP-130/80 mm Hg. Troponin I was normal.
Figure: ECG showing Wide spread ST segment elevation in lead 1, II, III,
aVF, aVL, V4-V6 suggestive of acute Pericarditis.

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ST segment
Professor DrMdToufiqurRahman
Fundamentals of ECG
Case: A 54 years old lady presented with chest discomfort and excessive sweating for
last 4 hours. She was diabetic, hypertensive and dyslipidemic. Her pulse 62b/min
and BP-160/90 mm Hg. In emergency department she had the following ECG.
Figure: ST segment elevation in inferior leads (II, III, aVF)suggestive of inferior
myocardial infarction and there is reciprocal ST segment depression in lead 1, aVL.

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ST segment
Professor DrMdToufiqurRahman
Fundamentals of ECG
Case: A 23 years old gentleman presented with occasional chest
discomfort. He was smoker, normotensive and non-diabetic. He had
the following ECG. His Echocardiogram was normal and troponin I level
was normal.
ECG showing characteristic ST segment elevation in V1-V3 suggestive
of Benign early repolarization (BER).

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ST segment
Professor DrMdToufiqurRahman
Fundamentals of ECG
Case: A 33 years old gentleman presented with occasional chest discomfort, dizziness
and several episodes of syncope. He had an ejection systolic murmur in precordium,
BP-95/60 mm Hg. Echocardiogram showed bicuspid aortic valve and aortic valve
gradient was 123 mm Hg. He had the following ECG.
Figure: ECG showing ST segment elevation in lead 1, aVL, V1-V4 with
withspecific pattern of LBBB. There is prolonged PR interval
suggestive of presence of first degree AV block.

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ST segment
Professor DrMdToufiqurRahman
Fundamentals of ECG
Case: A 43 years old lady presented with headache for 2 months. Her
BP-160/100 mm Hg. Her echocardiogram showed concentric left
ventricular hypertrophy. She had the following ECG.
Figure: S wave in V1/V2+ R in V5/V6 more than 35 mm suggestive of
Left ventricular hypertrophy. In V1-V2 there is deep s wave with ST
segment elevation.

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ST segment
Professor DrMdToufiqurRahman
oTheST segmentis the flat, isoelectric section
of the ECG between the end of the S wave (the
J point) and the beginning of the T wave.
oThe ST Segment represents the interval
between ventricular depolarization and
repolarization.
oThe most important cause of ST segment
abnormality (elevation or depression)
ismyocardial ischaemiaorinfarction.
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Causes of ST Segment Elevation
Acute myocardial infarction
Coronary vasospasm (Printzmetal’sangina)
Pericarditis
Benign early repolarization
Left bundle branch block
Left ventricular hypertrophy
Ventricular aneurysm
Brugadasyndrome
Ventricular paced rhythm
Raised intracranial pressure
TakotsuboCardiomyopathy
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Morphology of the Elevated ST segment
Myocardial Infarction
Acute STEMI may
produce ST elevation
with either concave,
convex or obliquely
straight morphology.
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Morphology of the Elevated ST segment
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Morphology of the Elevated ST segment
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Morphology of the Elevated ST segment
Patterns of ST Elevation
Acute ST elevation myocardial infarction (STEMI)
ST segment elevation and Q-wave formation in contiguous
leads.
Septal(V1-2)
Anterior (V3-4)
Lateral (I + aVL, V5-6)
Inferior (II, III, aVF)
Right ventricular (V1, V4R)
Posterior (V7-9)
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Morphology of the Elevated ST segment
Acute ST elevation myocardial infarction (STEMI)
There is usuallyreciprocal ST depressionin the electrically
opposite leads. For example, STE in the high lateral leads I +
aVLtypically produces reciprocal ST depression in lead III
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Coronary Vasospasm (Prinzmetal’sangina)
•This causes a pattern of ST elevation that is very
similar to acute STEMI —i.e. localisedST elevation
with reciprocal ST depression occurring during
episodes of chest pain.
•However, unlike acute STEMI the ECG changes are
transient, reversible with vasodilators and not
usually associated with myocardial necrosis.
•It may be impossible to differentiate these two
conditions based on the ECG alone.
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Pericarditis
Acute Pericarditiscauses widespread
concave (“saddleback”) ST segment elevation
withPR segment depressionin multiple
leads, typically involving I, II, III, aVF, aVL, and
V2-6.
Spodick’ssignwas first described byDavid H.
Spodickin 1974 as a downward sloping TP
segment with specificity for acute pericarditis.
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Pericarditis
Concave “saddleback” ST elevation in leads I, II, III, aVF, V5-6
with depressed PR segments. There is reciprocal ST
depression and PR elevation in leads aVRand V1.
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Benign Early Repolarization
BenignEarlyRepolarization(BER)causesmildST
elevationwithtallT-wavesmainlyinthe
precordialleads.
BERisanormalvariantcommonlyseeninyoung,
healthypatients.
ThereisoftennotchingoftheJ-point—the“fish-
hook”pattern.
TheSTchangesmaybemoreprominentatslowerheart
ratesanddisappearinthepresenceoftachycardia.
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Benign Early Repolarization
There is slight concave ST elevation in the precordial and inferior leads
with notching of the J-point (the “fish-hook” pattern)
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Left Bundle Branch Block (LBBB)
•InLeftbundlebranchblock(LBBB),theST
segmentsandTwavesshow“appropriate
discordance”—i.e.theyaredirectedoppositeto
themainvectoroftheQRScomplex.
•ThisproducesSTelevationanduprightTwavesin
leadswithanegativeQRScomplex(dominantS
wave),whileproducingSTdepressionandTwave
inversioninleadswithapositiveQRScomplex
(dominantRwave).
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Left Bundle Branch Block (LBBB)
ST elevation in leads with deep S waves —most apparent in V1-3.
ST depression in leads with tall R waves —most apparent in I and
aVL.
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Left Ventricular Hypertrophy (LVH)
Left Ventricular Hypertrophy(LVH)
causes a similar pattern of
repolarization abnormalities as LBBB,
with ST elevation in the leads with
deep S-waves (usually V1-3) and ST
depression/T-wave inversion in the
leads with tall R waves (I, aVL, V5-6).
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Left Ventricular Hypertrophy (LVH)
•Deep S waves with ST elevation in V1-3
•ST depression and T-wave inversion in the lateral leads V5-6
•there is alsoright axis deviation, which is unusual for LVH and may
be due to associatedleft posterior fascicular block
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Ventricular Aneurysm
•Ventricular Aneurysm–residual ST
elevation and deep Q waves seen in
patients with previous myocardial
infarction.
•It is associated with extensive myocardial
damage and paradoxical movement of the
left ventricular wall during systole.
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Ventricular Aneurysm
•ST elevation with deep Q waves and inverted T waves in V1-3.
•This pattern suggests the presence of a left ventricular aneurysm
due to a prior anteroseptalMI.
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
BrugadaSyndrome
•BrugadaSyndromeis an inherited
channelopathy(a disease of myocardial
sodium channels) that leads to paroxysmal
ventricular arrhythmias and sudden cardiac
death in young patients.
•The tell-tale sign on the resting ECG is the
“Brugadasign” —ST elevation and partial
RBBB in V1-2 with a “coved” morphology.
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
BrugadaSyndrome
•ST elevation and partial RBBB in V1-2 with a coved
morphology —the “Brugadasign”.
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Ventricular Paced Rhythm
Ventricular pacing(with a pacing wire in
the right ventricle) causes ST segment
abnormalities identical to that seen in
LBBB.
There isappropriate discordance, with the
ST segment and T wave directed opposite
to the main vector of the QRS complex.
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Ventricular Paced Rhythm
There isappropriate discordance, with the ST segment and T wave
directed opposite to the main vector of the QRS complex.
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Raised Intracranial Pressure
•Raised Intracranial Pressure(ICP) (e.g. due
to intracranial haemorrhage, traumatic
brain injury) may cause ST elevation or
depression that simulates myocardial
ischaemiaor pericarditis.
•More commonly, raised ICP is associated
with widespread, deep T-wave inversions
(“cerebral T waves“).
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Raised Intracranial Pressure
Widespread ST elevation with concave (pericarditis-like) morphology
in a patient with severe traumatic brain injury
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
TakotsuboCardiomyopathy
oTakotsuboCardiomyopathy, A STEMI mimic
producing ischaemicchest pain, ECG changes +/-
elevated cardiac enzymes with characteristic
regional wall motion abnormalities on
echocardiography.
oTypically occurs in the context of severe emotional
distress (“broken heart syndrome“). Commonly
associated with new ECG changes (ST elevation or T wave
inversion) or moderate troponin rise.
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
TakotsuboCardiomyopathy
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Less Common Causes of ST segment Elevation
Pulmonary embolismand acute corpulmonale
(usually in lead III)
Acute aortic dissection (classically causesinferior
STEMIdue to RCA dissection)
Hyperkalaemia
Sodium-channel blocking drugs(secondary to QRS
widening)
J-waves(hypothermia,hypercalcaemia)
Following electrical cardioversion
Others: Cardiac tumour, myocarditis, pancreas or
gallbladder disease
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
TransientSTelevationafterDC
cardioversionfromVF
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
J waves in hypothermia simulating
ST elevation
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Causes of ST Depression
Myocardial ischaemia/ NSTEMI
Reciprocal change in STEMI Posterior MI
Digoxin effect
Hypokalaemia
Supraventricular tachycardia
Right bundle branch block
Right ventricular hypertrophy
Left bundle branch block
Left ventricular hypertrophy
Ventricular paced rhythm
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Morphology of ST Depression
ST depression can be either upsloping,
downsloping, or horizontal.
Horizontal or downslopingST depression ≥ 0.5
mm at the J-point in ≥ 2 contiguous leads
indicates myocardial ischaemia(according to
the2007 Task Force Criteria).
UpslopingST depression in the precordial leads
with prominentDe Winter T wavesis highly
specific for occlusion of the LAD.
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Morphology of ST Depression
Reciprocal change has a morphology that
resembles “upside down” ST elevation and
is seen in leads electrically opposite to the
site of infarction.
Posterior MI manifests as horizontal ST
depression in V1-3 and is associated with
upright T waves and tall R waves.
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Morphology of ST Depression
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
ST segment morphology in myocardial ischaemia
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Morphology of ST Depression
Reciprocal change
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Morphology of ST Depression
ST segment morphology in posterior MI
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Morphology of ST Depression
MyocardialIschaemia
STdepressionduetosubendocardial
ischaemiamaybepresentinavariablenumberof
leadsandwithvariablemorphology.
Itisoftenmostprominentintheleftprecordial
leadsV4-6plusleadsI,IIandaVL.
WidespreadSTdepressionwithSTelevationin
aVRisseeninleftmaincoronaryartery
occlusionandseveretriplevesseldisease.
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Morphology of ST Depression
Myocardial Ischaemia
ST depression localisedto the inferior or high lateral leads is more likely to
represent reciprocal change than subendocardialischaemia
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Morphology of ST Depression
ReciprocalChange
•STelevationduringacuteSTEMIisassociatedwith
simultaneousSTdepressionintheelectricallyopposite
leads.
•InferiorSTEMIproducesreciprocalSTdepressioninaVL
(±leadI).
•LateraloranterolateralSTEMIproducesreciprocalST
depressioninIIIandaVF(±leadII).
•ReciprocalSTdepressioninV1-3occurswithposterior
infarction
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Morphology of ST Depression
Reciprocal Change
Reciprocal ST depression in aVLwith inferior STEMI
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Morphology of ST Depression
Reciprocal Change
Reciprocal ST depression in III and aVFwith high lateral STEMI
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Posterior Myocardial Infarction
AcuteposteriorSTEMIcausesSTdepressionintheanteriorleadsV1-
3,alongwithdominantRwaves(“Q-waveequivalent”)anduprightT
waves.ThereisSTelevationintheposteriorleadsV7-9.
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
De Winter T Waves
DeWinterTwaves:apatternofup-slopingSTdepressionwith
symmetricallypeakedTwavesintheprecordialleadsisconsideredto
beaSTEMIequivalent,andishighlyspecificforanacuteocclusionof
theLAD.
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Digoxin Effect
DigoxinEffect:Treatmentwithdigoxincausesdownsloping
STdepressionwitha“sagging”morphology,reminiscentof
SalvadorDali’smoustache.
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Hypokalaemia
HypokalaemiacauseswidespreaddownslopingST
depressionwithT-waveflattening/inversion,prominentU
wavesandaprolongedQUinterval.
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Right ventricular hypertrophy (RVH)
Right ventricular hypertrophy(RVH) causes ST depression
and T-wave inversion in the right precordial leads V1-3.
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Right Bundle Branch Block (RBBB)
Right Bundle Branch Block(RBBB) may produce a similar
pattern of repolarisationabnormalities to RVH, with ST
depression and T wave inversion in V1-3.
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Supraventricular tachycardia (SVT)
Fundamentals of ECG

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ST segment
Professor DrMdToufiqurRahman
Supraventricular tachycardia (SVT)
Supraventriculartachycardia(e.g.AVNRT)typicallycauseswidespreadhorizontalST
depression,mostprominentintheleftprecordialleads(V4-6).
Thisrate-relatedSTdepressiondoesnotnecessarilyindicatethepresenceof
myocardialischaemia,providedthatitresolveswithtreatment.
Fundamentals of ECG