ECGs in Acute Coronary Syndrome

various types of ECGs in ACS
some are from online
some are real ECGscenarios

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

10. 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 . Rate related ST-T changes. ECG with significant ST-T changes, needs early reperfusion Severe mitral regurgitation Atrial tachycardia

11. B. ECG with ST-T changes needs early reperfusion

12. 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.

13. 43 M was diagnosed with lateral subendocardial ischemia based on ST depression in AVL. Do you agree ? A. Yes B.No

14. It is an inferior wall STEMI

15. 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

16. Wellen’s syndrome Type II (or Pattern A)

17. 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.

18. 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

19. De Winter T waves STEMI equivalent Seen in 2% patients with AWMI should receive reperfusion therapy PCI or Thrombolysis

20. 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

21. 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

22. Answer Do treadmill test CAG Fragmented QRS complexes in inferior leads

23. 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.

24. 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

25. B. Wellen’s syndrome type A Had critical lesion in proximal LAD PTCA +Stent to LAD done asymptomatic

26. A 54 /M, Severe AR admitted with rest angina. Does he needs Evalaution for CAD A. Yes B.No

27. Inverted U waves in lateral leads are suggestive of ischemia

28. 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.

29. 65 f shortness of breath class II since 15 days.Class III since 2 days. Diabetic ,Hypertensive Rate related ST-T depression, T wave inversions NSTEMI C Evolved AWMI D. Stable angina

30. B.NSTEMI

31. 57 M, f/h/o CAD, DOE since 10 days .He was stabilized. Do angiography B. Treadmill Test C. Viability test D. Dobutamine stress echo

32. 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

33. To be read article

34. Some of the ECGs www.ecg-maven.com All variety of ECGS for assessment with various levels of grading www.lifeinthefastlane.com

35. 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.

36. Thank you