The document discusses ECG patterns that can help identify acute coronary syndromes including ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), and unstable angina. Key ECG indicators of ischemia, injury, and infarction are ST segment changes, T wave changes, and presence of Q waves. ST elevation in two contiguous leads with chest pain symptoms indicates STEMI. The document provides guidance on cut-off points for ST elevation in different leads to diagnose STEMI and evaluating right ventricular involvement or posterior infarction. Repeating ECGs can help identify early changes in cases of suspected STEMI.

1. For PHT paramedics
ACS ECG

2.  Clinical presentations ranging from those for
A. ST-segment elevation myocardial infarction(STEMI)
B. Non –ST-segment elevation myocardial infarction (NSTEMI) or
UNSTABLE ANGINA

3.  The ECG can help identify the presence of ishemia,injury,and/or
infarction of the heart muscle
 The 3 key ECG indicators are:
1. ST segment changes (depression or elevation)
2. T wave (peaking or inversion)
3. Q wave (enlarged or appearance of new Q wave

4. The graphic is a reminder about the
normal complexes and segments.
Remember for ischemia and infarction,
we are interested in the ST segment, T
wave and the presence of Q waves.

5. 50/M/M
EPIGESTRIC
PAIN

8. ISCHEMIA
•T wave inversion, ST segment depression
•Acute injury: ST segment elevation
•Dead tissue: Q wave

10. ST-SEGMENT ELEVATION

11. Can be characterised as:-
►Downsloping
►Upsloping
►Horizontal

12. EKG CHANGES: ISCHEMIA →
ACUTE INJURY→ INFARCTION

14. EVOLUTION OF A SUBENDOCARDIAL
INFARCTION

16. HYPERACUTE T WAVES

17. Q WAVES
Non Pathological Q waves
Q waves of less than 2mm are normal
Pathological Q waves
Q waves of more than 2mm
indicate full thickness myocardial
damage from an infarct
Late sign of MI (evolved)

19.  The presence of ST elevation in two contiguous leads in patients
with symptoms of ischaemia is the cardinal feature of STEMI.
 The cut-off points for new or presumed new ST segment elevation (in
the absence of LVH and LBBB) is the presence of ≥ 0.1 mV ST
segment elevation in all leads except leads V2-V3.
 In leads V2-V3, a cut-off point of ≥ 0.25 mV (in males < 40 years), ≥
0.2 mV (in males ≥ 40 years) and ≥0.15 mV in females is used
 The presence of a new onset or presumed new LBBB in a patient
with typical chest pain of ischaemia may indicate an infarct and
should be treated as STEMI

20.  In the early stages of MI, the initial ECG may be normal, equivocal or
show hyperacute T-wave changes only. In these patients if the index of
suspicion of STEMI is high, the ECG should be repeated at close
intervals of at least 15 minutes to look for progressive ST changes.
 Inferior STEMI should have an ECG recording of the right praecordial
lead (V4R) to identify concomitant right ventricular
(RV)involvement.
 In those with ST segment depression in leads V1-V3, it is advisable
to have an ECG recording of the posterior chest wall (V7-V9) to
identify a true infero-basal (formerly known as infero-posterior)STEMI.
The cut-off point for ST segment elevation in the posterior leads is ≥
0.05 mV (≥ 0.1 mV in men < 40 years).
 ST elevation in lead AVR may be a predictor of left main/3 vessel CAD
and carries an adverse prognosis

26. RIGHT SIDED ECG

27. POSTERIOR ECG