This document focuses on ECG recognition, detailing key conditions such as STEMI, MI mimics, and changes due to electrolyte disorders. It describes specific ECG patterns associated with various cardiac conditions and the diagnostic criteria for these abnormalities. Additionally, it emphasizes the importance of recognizing these patterns for effective clinical decision-making.

1. ECG RECOGNITION : ECGS THAT
YOU MUST NOT MISSED
PRESENTED BY
DR MOHD HABROL AFZAM BIN ABD WAHAB
SUPERVISED BY
NORASLAWATI BINTI RAZAK

2. CONTENTS
• STEMI : RECOGNITION OF STEMI AND EXAMPLES OF ECG
• MI MIMICS AND EXAMPLES : BRUGADA / WELLENS / DE WINTER / PERICARDITIS / BER
• ECGS CHANGES SECONDARY TO ELECTROLYTES DISORDER
• BRADYARRYTHMIAS

3. ST ELEVATION MYOCARDIAC
INFARCTION

4. RECIPROCAL CHANGES IN STEMI
STEMI TERRITORY STE LEADS RECIPROCAL CHANGES
SEPTAL / ANTERIOR V1-V2 / V3-V4 II, III, AVF
LATERAL I, AVL, V5-V6 II, III, AVF
INFERIOR II, III, AVF I AND AVL
POSTERIOR V7, V8, V9 V1-V3

5. Are all STE = STEMI ?

7. 40 YEARS OLD, DM, CHEST PAIN SINCE 2HS
• ST elevation and hyperacute T waves in V2-4
• ST elevation in I and aVL with reciprocal ST depression in lead III
• Q waves are present in the septal leads V1-2
• These features indicate a hyperacute anteroseptal STEMI

8. 40 YEARS OLD, DM, CHEST PAIN SINCE 2HS
• ST elevation is present in the high lateral leads (I and aVL).
• There is also subtle ST elevation with hyperacute T waves in V5-6.
• There is reciprocal ST depression in the inferior leads (III and aVF) with associated ST depression in V1-3
(which could represent anterior ischaemia or reciprocal change). This is high lateral STEMI

9. 45 YEARS OLD, HPT, SOB AND DIAPHORESIS SINCE 4H
In this ECG, posterior MI is suggested by the presence of:
• ST depression in V2-3 , Tall, broad R waves (> 30ms) in V2-3
• Dominant R wave (R/S ratio > 1) in V2, Upright terminal portions of the T waves in V2-3
• Posterior ECG done on next slide

10. • Posterior infarction is diagnosed based on the presence of ST segment elevation >0.5mm in leads V7-9.
45 YEARS OLD, HPT, SOB AND DIAPHORESIS SINCE 4H

11. Reference : LITFL ST Segment

12. STEMI MIMICs

13. Reference : LITFL ST Segment
Brugada Syndrome
• Brugada Syndrome is an
ECG abnormality with a high
incidence of sudden death
in patients with structurally
normal heart
• The mean age of sudden
death is 41, with the age at
diagnosis ranging from 2
days to 84 years.
• Incidence high in Southeast
Asia where it had been
previously described as
Sudden Unexplained
Nocturnal Death Syndrome
(SUNDS).
• High risk VT / VF
• Definitive treatment = ICD.
• Brugada sign in isolation is
of questionable
significance.
Type 1
• Coved ST segment
elevation >2mm in
>1 of V1-V3 followed
by a negative T
wave.
Type 2
• Has >2mm of
saddleback shaped ST
elevation.

14. Reference : LITFL ST Segment
Brugada Syndrome

15. Reference : LITFL ST Segment
Type 2
• Has >2mm of saddleback shaped ST elevation.

16. Reference : LITFL ST Segment
Wellens Syndrome
• Clinical syndrome characterised
by biphasic or deeply inverted T waves
in V2-3, plus a history of recent chest pain
now resolved.
• It is highly specific for critical stenosis of
the left anterior descending artery (LAD)

17. Reference : LITFL ST Segment
Wellens Syndrome (Type A Pattern)
• Biphasic precordial T waves with terminal negativity,
most prominent in V2-3
• Minor precordial ST elevation
• Preserved R wave progression (R wave in V3 > 3mm)

18. Reference : LITFL ST Segment
Wellens Syndrome (Type B Pattern)
• There are deep, symmetrical T wave inversions
throughout the anterolateral leads (V1-6, I, aVL)

19. BENIGN EARLY REPOLARIZATION VS PERICARDITIS

20. Reference : LITFL ST Segment
Typical morphology of BER
The ST segment-T wave complex in BER has a characteristic appearance:
• There is elevation of the J point
• The T wave is peaked and slightly asymmetrical
• The ST segment and the ascending limb of the T wave form an upward
concavity
• The descending limb of the T wave is straighter and slightly steeper than
the ascending limb
One characteristic feature of BER is the presence of a notched or irregular
J point: the so-called “fish hook” pattern. This is often best seen in lead V4.

21. Reference : LITFL ST Segment
• ST segment height = 1 mm
• T wave height = 6 mm
• ST / T wave ratio = 0.16
• The ST / T wave ratio < 0.25 is
consistent with BER
• ST segment height = 2 mm
• T wave height = 4 mm
• ST / T wave ratio = 0.5
• The ST / T wave ratio > 0.25 is
consistent with pericarditis

22. Reference : LITFL ST Segment
Acute Pericarditis:
•Widespread concave ST elevation and PR depression
is present throughout the precordial (V2-6) and limb
leads (I, II, aVL, aVF).
•There is reciprocal ST depression and PR elevation in
aVR.
PR depression and ST elevation in V5

23. Reference : LITFL ST Segment
Acute Pericarditis:
• Sinus tachycardia
• Widespread concave STE and PR depression (I, II,
III, aVF,
V4-6)
• Reciprocal ST depression and PR elevation in V1
and aVR
• Spodick’s sign best visualised in lead II
Downsloping TP segment seen as an early ECG manifestation in ~30% of patients
with pericarditis, best visualised in leads II and the lateral precordial leads

24. Reference : LITFL ST Segment
ECG of Benign Early Repolarisation (BER), demonstrating:
1) Generalised concave ST elevation in precordial (V2-6) and limb leads (I,
II, III, aVF)
2) J-point notching / Slurred is evident in the inferior leads (II, III and aVF)
3) ST elevation : T wave ratio < 0.25 in V6

25. Reference : LITFL ST Segment
ST elevation and J-point notching are more prominent at a slower heart rate.

26. Reference : LITFL ST Segment
Traumatic Brain Injury
• This ECG was taken from a previously healthy 18-year old girl with severe traumatic brain injury and
massively raised intracranial pressure (30-40 mmHg)
• There is widespread ST elevation with a pericarditis-like morphology and no reciprocal change (except in
aVR and V1)
• She had no cardiac injury / abnormality to explain the ST elevation
• The ST segments normalised as the intracranial pressure came under control (following treatment with

27. Reference : LITFL ST Segment

28. Reference : LITFL ST Segment

29. Reference : LITFL ST Segment

30. Reference : LITFL ST Segment

31. Reference : LITFL ST Segment
De Winter T Wave
-All three previous ECG are De winter T wave ECG = Anterior STEMI equivalent
ECG Diagnostic Criteria
• Tall, prominent, symmetrical T waves in the precordial leads
• Upsloping ST segment depression > 1mm at the J point in the precordial leads
• Absence of ST elevation in the precordial leads
• Reciprocal ST segment elevation (0.5mm – 1mm) in aVR
• Typical STEMI morphology may precede or follow the De Winter pattern
•The de Winter pattern is seen in ~2% of acute LAD occlusions and is often under-
recognised by clinicians

32. • ST elevation in aVR with co-existent multi-lead ST depression indicates subendocardial ischaemia due to
O2 supply/demand mismatch. Clinical causes include:
• Left main coronary artery (LMCA) stenosis
• Proximal left anterior descending artery (LAD) stenosis
• Severe triple vessel disease
• Hypoxia or hypotension, for example following resuscitation from cardiac arrest
STE in AVR

33. • PR interval < 120ms
• Delta wave: slurring slow rise of initial portion of the QRS
• QRS prolongation > 110ms
• Same features but without delta wave = Lown-Ganong-Levine (LGL) Syndrome
Wolff-Parkinson-White aka WPW Syndrome

34. Electrical Alternans in Massive Pericardiac Effusion

35. ELECTROLYTE DISORDER ECG
CHANGES

39. Bazett formula: QTC = QT / √ RR
Fridericia formula: QTC = QT / RR 1/3
Framingham formula: QTC = QT + 0.154 (1 – RR)
Hodges formula: QTC = QT + 1.75 (heart rate – 60)
The RR interval is given in seconds (RR interval = 60 / heart rate).
Normal QTc values
• QTc is prolonged if > 440ms in men or > 460ms in
women
• QTc > 500 is associated with an increased risk of
torsades de pointes
• QTc is abnormally short if < 350ms
• A useful rule of thumb is that a normal QT is less than
half the preceding RR interval

40. HYPOCALCAEMIA ECG
QTc 500ms in a patient with hypoparathyroidism (post thyroidectomy) and serum corrected calcium of 1.40
mmol/L

41. • Prolonged PR interval. Broad, bizarre QRS complexes — these merge with both the preceding P wave and
subsequent T wave. Peaked T waves.
HYPERKALAEMIA ECG

42. Sine wave appearance with severe hyperkalaemia (K+ 9.9 mEq/L).
HYPERKALAEMIA ECG

43. HYPOKALAEMIA ECG
Widespread ST depression and T wave inversion, Prominent U waves, Long QU interval
This patient had a serum K+ of 1.7

44. BRADYARRYTHMIAS

47. • HR < 60BPM
• REGULAR R TO R INTERVAL
• NO PROLONGED PR INTERVAL
• NO DROP BEAT
SINUS BRADYCARDIA

48. SINUS BRADYCARDIA

49. • REGULAR R TO R INTERVAL
• CONSTANT PROLONGED PR INTERVAL (>0.2s OR 5 SMALL BOXES OR 1 BIG BOX)
• NO DROP BEAT
1ST
DEGREE HEART BLOCK

50. 2ND DEGREE HEART BLOCK

51. 3RD DEGREE HEART BLOCK

53. 2ND
DEGREE HEART BLOCK, MOBITZ TYPE II

54. 2ND
DEGREE HEART BLOCK, MOBITZ TYPE II

55. 2ND
DEGREE HEART BLOCK, MOBITZ TYPE II
Acute Inferolateral, possible posterior involvement STEMI with complete heart block

56. HIGH GRADE AV BLOCK
• High-grade AV block (4:1 conduction ratio).
• Atrial rate is approximately 140 bpm.
• Ventricular rate is approximately 35 bpm.

57. THANK YOU