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Cardiac causes of ST-Segment Elevation - Dr. L. Littmann

2/22/2018

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Picture
I. Myocardial injury
  • In inferior MI, if ST elevation in lead III is greater than ST elevation in II: probable RCA occlusion
    • higher risk of bradycardia, AV block, atrial fibrillation and RV infarct (always with RCA MI)
  • In inferior MI, if ST elevation in lead II is greater than ST elevation in III: probable LCX occlusion
    • higher risk of papillary muscle dysfunction, acute mitral regurgitation, pulmonary edema
  • Presence of wide and deep Q waves suggests large transmural MI and no viability
    • in acute MI: probable late presentation, no viability
    • in remote MI: consider LV aneurysm
    • In acute anterior STEMI, new right bundle branch block suggests large MI and high mortality
  • Acute myocarditis can present with STEMI picture in the ECG
    • clinical presentation is different (severe acute heart failure, pulmonary edema)
    • ST elevation is frequently diffuse
    • conduction abnormalities (A-V block) are frequently present
 

II. Secondary ST-segment elevation
  • With wide QRS complexes (left bundle branch block, ventricular pacing, WPW)
    • QRS and ST-Ts are usually discordant: discordant ST elevation is normal
    • ST elevation that is concordant with the QRS complexes strongly suggests STEMI
  • In severe LVH with narrow QRS complexes
    • QRS/ST-Ts are usually discordant: ST elevation in the anterior chest leads may be normal
    • in questionable cases, compare with old ECGs; perform serial ECGs; stat bedside echo
 

III. Terminal notching of the QRS complexes followed by hammock-shaped ST elevation
  • Pericarditis
    • tachycardia
    • ST elevation is diffuse but usually spares leads aVR and V1
    • depressed PR segment in lead I; elevated PR segment in lead aVR
  • Hypothermia
    • bradycardia
    • large and diffuse terminal QRS notching (Osborn waves)
    • prolonged QT
    • shivering artifact
  • Benign early repolarization
    • frequently present in young African-American males
    • terminal QRS notch and hammock-shaped ST elevation usually best seen in V4
    • heart rate and QT are usually normal
    • concern about risk of ventricular arrhythmia and sudden death in certain small subgroups
 

IV. Brugada syndrome, Brugada sign
  • High take-off upward convex (“coved”) ST elevation followed by negative T waves in V1 and V2
  • Increased risk of sudden cardiac death
  • Endemic in South-East Asia (Laos, Vietnam, Cambodia, Thailand)
  • Male predominance
  • Highest risk of sudden death is in patients with resuscitated sudden death, h/o unexplained syncope, spontaneous and dynamic Brugada ECG pattern, nonsustained VT during monitoring
  • Most asymptomatic patients without the listed risk factors, especially those who are older at the time of diagnosis, are at minimal risk of unexplained sudden death (“Brugada sign”)

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