A 52-year-old male presented with chest pain. His ECG showed evolving inferior wall myocardial infarction. ST depression is more frequently seen in lead aVL than other leads for inferior MI. A 51-year-old female presented with prior chest pain and is now pain-free. Her ECG shows Wellens' syndrome type I pattern and she should be monitored closely in the ICCU. Fragmented QRS complexes can indicate ischemia or scar tissue and are associated with worse cardiac outcomes.

1. ECG in ACS
Case based
Dr. N.Praveen
MD,DM

2. 52 / M with chest pain. The ECG shows
A. Early repolarization variant B. Pericarditis
C. NSTEMI D. Inferior wall MI

3. • D. Evolving Inferior wall MI

4. reciprocal ST depression occurred more frequently in aVL
than in any other lead.
It seems that ST depression in aVL, by contrast to that in the
precordial leads, is found in the majority of patients with
evolving inferior wall myocardial infarction and is not
influenced by extension of the infarction to the right ventricle
or to the posterior wall.

5. 51 /F with chest pain 2 days prior to this tracing. Now pain free, what is the plan ?
A. Discharge and medical management with antiplatelets ,statins
B. Thrombolyse
C. Close monitoring in ICCU D. Should undergo Primary PCI

6. Answer
• C.close monitoring in ICCU
• Wellen’s syndrome Type I or pattern B

7. 44 /M , F/H/O CAD, recently underwent PTCA + stent to RCA, now
admitted with Typical angina. Admission Trop I is 0.01. Does the patient
have signs of ischemia in ECG? A. Yes B. No

8. Yes

9. After giving nikoran infusion and optimizing the antianginals
before discharge

11. 46 M, diabetic, had epigastric pain in afternoon at his work. Taken
antacid. At ER after two hours with mild pain this was the ECG.
A. Rate related ST-T changes.
B. ECG with significant ST-T changes,
needs early reperfusion
C. Severe mitral regurgitation
D. Atrial tachycardia

12. • B. ECG with ST-T changes needs early reperfusion

13. Furthermore, the magnitude of ST segment elevation in lead
aVR greater than or equal to that of ST-segment elevation in
lead V1 was found to have 81% sensitivity and 80%
specificity for differentiating acute LMT occlusion from acute
LAD occlusion.

14. 43 M was diagnosed with lateral subendocardial ischemia based
on ST depression in AVL. Do you agree ?
A. Yes B.No

15. It is an inferior wall STEMI

16. A 46 /M, sm+,daily worker had left side chest pain in the night, muscle
cramps. The pain subsided after few minutes. The next day he walked into
ER. This is the ECG, what is the next plan.
A. Check calcium B. Do MRI Brain (cerebral T waves)
C. Admit the patient in ICCU. D.Old Anterior wall MI needs MMx

17. Wellen’s syndrome Type II (or Pattern A)

18. American Heart Journal103;730. 1982
Of 145 patients consecutively admitted because of unstable angina, 26
(16%) showing this ECG pattern, suggesting that this finding is not rare.
In spite of symptom control by nltroglycerln and beta blockade,
12 of 16 patients (75%) who were not operated on developed a usually
extensive anterior wall infarction within a few weeks after admission.

19. 50 /M ,poorly controlled chronic diabetic had atypical chest pain.
This is the ECG at PHC what is the next plan?
A.Give loading dose of antiplatelets,thrombolyse
B.Junctional rhythm,needs pacemaker support
C.Rule out hyperkalemia
D.Evolved AWMI, give antiplatelets,statins

20. De Winter T waves
• STEMI equivalent
• Seen in 2% patients with AWMI
• should receive reperfusion therapy PCI or Thrombolysis

21. Instead of the signature ST-segment elevation, the ST segment showed a 1- to 3-mm
upsloping ST-segment depression at the J point in leads V1 to V6 that continued into
tall, positive symmetrical T waves. The QRS complexes were usually not widened or
were only slightly widened, and in some there was a loss of precordial R-wave
progression. In most patients there was a 1- to 2-mm ST-elevation in lead aVR.
We recognized this characteristic ECG pattern in 30 of 1532 patients with anterior
myocardial infarction (2.0%).
Robbert J. de Winter, M.D., Ph.D.,Niels J.W. Verouden, M.D.
Hein J.J. Wellens, M.D., Ph.D.,Arthur A.M. Wilde, M.D., Ph.D.
1100 DD Amsterdam, the Netherlands
N Engl J Med 359;19 November 6, 2008 2071

23. A 56 F, washer woman DM, HTN, Hypothyroidism. Had left upper limb pain on
daily work since 15 days. Echo was normal. This is the ECG ?
A.Normal ECG give analgesics B. Observe for 24 hours send troponin
C.Do treadmill test ,CAG. D. Check electrolytes

24. Answer
• Do treadmill test
• CAG
• Fragmented QRS complexes in inferior leads

25. Fragmented QRS is defined as the presence of R’ wave or notching
of R or S wave in the presence of narrow QRS. It indicates
heterogeneous depolarization of the ventricular myocardium that
can occur due to ischemia, fibrosis, or scar. It may also be a
marker of coronary microvascular dysfunction. In the context of
epicardial coronary artery disease, it is associated with multivessel
disease and greater incidence of cardiac events.

26. A 70 year male no risk factors, H/O GERD, had left side chest pain for few
minutes, mild sweating. Relieved by belchings. Next day morning, he came to
ER. He was not having chest pain. What is the plan
A. Do treadmill test for ischemia
B. Loading doses of antiplatelets, statins, CAG- PTCA
C. GI Endoscopy
D. Do viability imaging

27. • B. Wellen’s syndrome type A
• Had critical lesion in proximal LAD
• PTCA +Stent to LAD done
• asymptomatic

29. A 54 /M, Severe AR admitted with rest angina.
Does he needs Evalaution for CAD A. Yes B.No

30. Inverted U waves in lateral leads are suggestive of ischemia

31. Sovari AA, Farokhi F, Kocheril AG.
Inverted U wave, a specific electrocardiographic sign of cardiac
ischemia. Am J Emerg Med. 2007 Feb;25(2):235 -7
Correale E.
The negative U wave: a pathogenetic enigma but a useful, often
overlooked bedside diagnostic and prognostic clue in ischemic
heart disease. Clin Cardiol 2004;27(12):674 - 7.

32. 65 f shortness of breath class II since 15 days.Class III since 2 days.
Diabetic ,Hypertensive
A.Rate related ST-T depression, T wave inversions
B.NSTEMI C Evolved AWMI D. Stable angina

33. • B.NSTEMI

34. 57 M, f/h/o CAD, DOE since 10 days .He was stabilized.
A.Do angiography B. Treadmill Test
C. Viability test D. Dobutamine stress echo

35. • A. Do angiography
ST depression (especially horizontal or downsloping) is highly
suggestive of NSTE-ACS .
Marked symmetrical precordial T-wave inversion (≥2 mm [0.2 mV])
suggests acute ischemia, particularly due to a critical stenosis of
the left anterior descending coronary artery; it may also be seen
with Acute PE and right sided ST-T changes.
2014 ACC –AHA NSTEMI guidelines

37. To be read article

38. Some of the ECGs
• www.ecg-maven.com
• All variety of ECGS for assessment with various
levels of grading
• www.lifeinthefastlane.com

39. Take home message
 1.Whenever in doubt of ST elevation in inferior leads ,look at lead
AVL – ST depression, T inversion – tell tale sign of ischemia.
 2. Anterior precordial leads – Biphasic T inversions, Deep T wave
inversions – no angina – needs evaluation as AWMI.
 3.Anterior precordial leads – J point depression ,Tall T waves – needs
evaluation as STEMI
 4.ST elevation in AVR to be kept in mind,whenever there are ST
depressions in multiple leads.
 5.Inverted U waves in a patient with AR, chronic HTN – suggestive of
ischemia.

40. Thank you