1) The document discusses various ECG patterns and their significance, including ST elevation in aVR indicating left main coronary artery occlusion, T wave inversion in aVL indicating inferior STEMI, factors favoring STEMI vs pericarditis, Wellens' syndrome indicating high risk for anterior MI, and modified Sgarbossa criteria for LBBB patterns. 2) It provides guidance on diagnosing conditions like Brugada pattern vs Wellens' syndrome and avoiding diagnosing benign early repolarization in older patients. 3) The importance of serial ECGs and discussing ambiguous cases with cardiologists is emphasized.

2. ALMANA GROUP OF HOSPTALS – DAMMAM
Dr. AHMED ELAMIN AWADELARIM
ECG challenges

3. Saving lives is stressful.
Mastering the ECG
shouldn’t be.

5. 35 years diaphortic, he had chest pain and pain
free
where’s the abnormality ? What’s your diagnosis?

6. where’s the abnormality ? What’s your diagnosis?

7. ST Elevation in aVR
WHY?
1) LMCA occlusion, especially if:
- ST elevation in aVR > V1. (highly specific)
- ST elevation in aVR & aVL.
2) Proximal LAD occlusion.
3) Triple vessel disease.

8. ST Elevation in aVR
recent study by Kosuge et al. (2011):
Patients with ≥ 1 mm STE in aVR may potentially require
early CABG; therefore these patients should ideally be
discussed with the interventional cardiologist (± cardiac
surgeon) before clopidogrel is given.
NOT A GUIDELINES YET.

9. 45 YEAR OLD HAD CHEST PAIN AT HOME FEW
HOURS BACK

10. 2nd ECG

12. T inversion in lead aVL
lead avl is the reciprocal lead for inferior stemi. here with
lead avl inverted
Comes first in many of inferior STEMI

13. 30 year old, chest pain

14. 27 years with central chest pain has fever t 37.8

15. Pericarditis
 Diffuse ST elevation
 Benign morphology
 PR depression is diagnostic
 Clinical presentation:
 Stabbing / burning; worse lying flat / relieved sitting
up; persistent and prolonged

16. Factors that strongly favor STEMI
1) Presence of reciprocal changes, (ST Depression other
than in aVR & V1).
2) STE III > STE II (progressive – sign of RCA lesion).
3) ST elevation is not concave, i.e convex or horizontal
“although it could be concave”.
4) New Q waves.
5) “Checkmark sign”

17. Factors that strongly favor Pericarditis
1) Widespread ST elevation & PR segment depression in
most of the limb leads & in V2-V6.. (This discordance is
characteristic)
2) ST elevation is concave upwards (saddle shape).
3) Reciprocal ST depression & PR segment elevation in
aVR & V1.
4) Spodick’s Sign.
5) Sinus tachycardia, due to pain +/_ effusion.

19. 35 YEAR OLD, NO PMH, HEALTHY AND FIT

20. BER
Usually the patient will be:
- Young athlete.
- Afro-Caribbean.
- almost always male.
- high voltage ECG.
- fish hook pattern in some leads.
-happy face contour.

22. 55 YEAR OLD, DIABETIC, CHEST PAIN

23. 51 YEAR OLD, EPAGASTRIC PAIN, DIAPHORETIC

24. DE WINTER’S WAVE
anterior STEMI equivalent that presents without
obvious ST segment elevation.
ST depression and peaked T waves in the precordial
leads.
2% of acute LAD occlusions.

25. DE WINTER’S WAVE
 2008 case series by DE Winter and Wellens
30 / 1532 patients with acute LAD occlusions (2% of cases).
 2009 case series by Verounden and colleagues
replicated this findings.
35 / 1890 patients requiring PCI to the LAD (2% of cases)
 Patients with chest pain and this ECG pattern should
receive emergent re-perfusion therapy with PCI or
thrombolysis.

27. 54 YEAR OLD, CHEST DISCOMFORT, K/O DM

28. FREE OF PAIN
WITH PAIN
48 year with chest pain

30. 60 YEAR OLD , HAD CHEST PAIN AT NIGHT , NOW
FREE OF PAIN

31. WELLEN’S SYNDROME
 deeply inverted or biphasic T waves in V2-3.
 highly specific for a critical stenosis of the left anterior
descending artery (LAD)
 high risk for extensive anterior wall MI within the next
few days to weeks.
 Needs urgent intervention in the same or next
days,poorly responds to medical treatment.

32. WELLEN’S SYNDROME
 First described in 1982 by Professor Hein J. J.
Wellens.
 The significance of it that could be sent home from the
emergency department
 Welleniod t waves can be seen in different diseases
such as: PE, RBBB, brugada synd.

33.  Biphasic T Waves (Type A)

34. Deeply Inverted T Waves (Type B)

37. LBBB
 Concordant ST elevation > 1mm in leads with a
positive QRS complex (score 5)
 Concordant ST depression > 1 mm in V1-V3 (score 3)
 Excessively discordant ST elevation > 5 mm in leads
with a negative QRS complex (score 2)
specific, but not sensitive for myocardial infarction

38. Smith’s modified Sgarbossa Criteria
 ≥ 1 lead with ≥1 mm of concordant ST elevation
 ≥ 1 lead of V1-V3 with ≥ 1 mm of concordant ST
depression
 ≥ 1 lead anywhere with ≥ 1 mm STE and proportionally
excessive discordant STE, as defined by ≥ 25% of the
depth of the preceding S-wave.

40. TAKEHOME POINTS
 Serial ECGs
 Never to consider Pericarditis in presence of:
ST depression other than in aVR & V1.
Convex or horizontal ST elevation.
 Try and avoid diagnosing BER in middle aged people,
and above 50 years as well.
 Do not diagonse BER in presence of t inversion in Avl.
 STEMI equivelant comes in pt with no chest pain.
 LBBB = Sgarbossa criteria OR smith’s modified
Sgarbossa

41. Thank you