Critical Ischemia - Dr. Littmann

I.  STEMI without STE

1. Discussed last month
2. ST depression in anterior chest leads: consider posterolateral STEMI – electrodes to the back
3. Subtle ST elevation in I, aVL, V2, ST depression in III (“South African flag sign”): consider high lateral STEMI – place V4-V5-V6 1 and 2 interspaces higher
4. Subtle ST elevation in the inferior leads with ST elevation in V1 but not in V2: probable RV MI – obtain right-sided chest leads
5. Medical emergency; door-to-balloon time < 90 min

 
II.  de Winter sign

1. Usually in young males who present with severe chest pain
2. Always in the chest leads
3. J-point depression followed by upsloping ST segments followed by tall “hyperacute” T waves
4. Usually signifies subtotal or total occlusion of proximal LAD
5. Medical emergency; immediate cath

 
III.  aVR sign

1. Presentation with acute chest pain (ACS)
2. Diffuse ischemic ST depression
3. ST elevation in aVR ≥ 1 mm
4. ST elevation in aVR usually higher than ST elevation in V1
5. 80% specific for left main or left main equivalent coronary artery obstruction
6. High risk of acute MI and cardiogenic shock, death
7. Urgent cath indicated (probably within hours)

 
IV.  Wellens sign

1. Presentation with acute chest pain (ACS)
2. Deep symmetrical T-wave inversion in the anterior chest leads, or
3. Biphasic (positive-negative) T waves in the anterior chest leads
4. Suggests tight proximal LAD occlusion
5. High mortality without cardiac cath, PCI
6. Most patients should undergo cardiac catheterization
7. Degree of urgency is uncertain

---