Emergency Medicine Reference

1. S.T.E.M.I.
Catching Mimics
With Mnemonic
PART B
MyEZG
TM
Workshop

2. PART B
1. We have completed all the five sub-
components of letter ‘S’ in Part A.
2. We now move on to the second letter ‘T’
that comprises four sub-components.
3. T1, T2, T3 & T4.

3. “Tall R wave”
means that
R is longer than S
T1
=
Tall
R
wave
in
V1/V2/V3
RVH
Posterior
STEMI

4. Tall R wave =
R is longer than S
T1
=
Tall
R
wave
in
V1/V2/V3
RVH
Posterior
STEMI
RAD

5. Tall R wave = R is longer than S
◆Check for presence of
RAD
◆If yes = RVH
◆Note: 90% of RVH
have RAD. If concern
for RVH exist but not
tall by proportion,
then measure:
◆R in V1 >7mm
◆S in V6 >7mm
⚫ RVH have secondary
ST-T changes.
⚫ May mimic NSTEMI
⚫ Mimic S1Q3T3
⚫ Cant diagnose LPFB
T1
=
Tall
R
wave
in
V1/
V2
/
V3

7. Diagnosis of posterior STEMI
Directly Indirectly
◆Posterior lead ECG V7, V8
& V9
◆0.5mm STE in any one lead
All three changes needed to
be present but only in one
lead ( V1 to V3)
◆Tall R wave (R>S)
◆STD esp flat
◆Upright T wave

9. T2
=
Tall
and
Tented
T
o Peak T wave
o Prolonged PR interval
o Flattening of P waves
o Wide QRS complex
o Sine wave
Hyperkalemia
⚫ The ‘syphilis’ of clinical ECG
⚫ Features include:

10. What is the main abnormality seen here?

12. T3
=
Thailand Brugada Syndrome

15. Brugada Syndrome
T3
=
Thailand
Note: ECG morphologies may transform from one type to the other or may
normalize completely

16. ◆ The Osborn wave (J wave
or J-point notching):
◆ Positive deflection at J point
◆ Negative deflection in aVR
and V1
◆ Prominent in precordial leads
◆ Bradycardia (including AV
block) are also common in
moderate and severe
hypothermia
Hypothermia - Osborn Waves
T4
=
Temperature

18. T components Diagnosis/Conditions
◆T1 = Tall R in V1/V2/V3.
◆T2 = Tall and tented T
◆T3 = Thailand
◆T4 = Temperature
◆RVH or Posterior STEMI
◆Hyperkalemia
◆Brugada syndrome
◆Hypothermia
S.T4E.M.I. Mnemonic

19. List of conditions
1. AMI (STEMI)
2. Pericarditis
3. LVH
4. LBBB
5. Paced ventricular
rhythm
6. Prinzmetal angina
7. RVH
8. Posterior STEMI
9. Early Repolarization
10. Hyperkalemia
11. Cerebrovascular event
12. Hypothermia
13. Left ventricular
aneurysm
14. WPW syndrome
15. Takotsubo
CMP/syndrome
MyEZG
Workshop

20. E1
=
Early
Repolarization
/
BER Early Repolarization Syndrome (ERS)
In 2015, Hancock et al proposed:
◆ The QRS slur or notch (termed a J wave)
must be on the downslope of the R wave
and be above the isoelectric line;
◆ The peak of the J point must be elevated ≥
0.1 mV in two or more contiguous leads
except V1-V3
◆ The QRS duration must be < 120 ms

21. E1
=
Early
Repolarization
/
BER

23. E2
=
Event
Cerebrovascular
Cerebrovascular Event
◆Clinical presentation usually obvious
◆Hemorrhagic stroke
◆ICB
◆Raised ICP
◆SAH

24. Takotsubo Syndrome (TTS) / Stress CMP
⚫May mimic anteroseptal STEMI
⚫It is difficult to differentiate by ECG alone
⚫Suspicion based on presentation, new ECG
changes
⚫ECG involve may cross territory
⚫Trigger: Post menopausal women= Emotional
trigger
⚫Male = Physical trigger
⚫Mayo Clinic criteria
E3
=
Excess
catecholamines

26. Left Ventriculogram

27. E components Diagnosis/Conditions
◆E1 = Early Repolarization
◆E2 = Event
Cerebrovascular
◆E3 = Excess
catecholamines
◆ERS / BER
◆Changes secondary to
brain insult
◆Takotsubo syndrome
S.T.E3M.I. Mnemonic

28. List of conditions
1. AMI (STEMI)
2. Pericarditis
3. LVH
4. LBBB
5. Paced ventricular
rhythm
6. Prinzmetal angina
7. RVH
8. Posterior STEMI
9. Early Repolarization
10. Hyperkalemia
11. Cerebrovascular event
12. Hypothermia
13. Left ventricular
aneurysm
14. WPW syndrome
15. Takotsubo
CMP/syndrome
MyEZG
Workshop

29. Left Ventricular Aneurysm (LVA)
◆Persistent STE following trans-mural infarct
◆2/52 if thrombolysis
◆6/52 if w/o intervention
◆Mostly in precordial leads (V1-V6)
◆Features include:
◆Convex (coving) STE morphology (KIV concave)
◆Well formed Q wave
◆Shallow T wave inversion ~ 1/3
◆Not 2/3 of Q wave depth
M1
=
Myocardial
Bulging

31. Wolff-Parkinson-White Syndrome
◆ Recognized by:
◆Delta wave – slurring on the upstroke of R wave
◆Short PR interval
◆ Abnormal depolarization with secondary ST-T
changes
◆ May mimic and obscure AMI
◆Affect inferior & anterior leads
◆ Delta wave - a pseudo-infarct pattern (Q wave)
M2
=
WPW
Syndrome
The ‘W’ in WPW is inverted to become ‘M’ in the mnemonic

32. Wolff-Parkinson-White Syndrome

33. M components Diagnosis/Conditions
◆M1 = Myocardial Bulging
◆M2 = M-inverted to-‘W’
◆Left Ventricular Aneurysm
◆WPW Syndrome
S.T.E.M2I. Mnemonic

34. List of conditions
1. AMI (STEMI)
2. Pericarditis
3. LVH
4. LBBB
5. Paced ventricular
rhythm
6. Prinzmetal angina
7. RVH
8. Posterior STEMI
9. Early Repolarization
10. Hyperkalemia
11. Cerebrovascular event
12. Hypothermia
13. Left ventricular
aneurysm
14. WPW syndrome
15. Takotsubo
CMP/syndrome
MyEZG
Workshop

35. Pericarditis
◆ The closest mimic (considered for every STEMI)
◆ Some AMI may cause pericarditis
◆ Not all ECG features are present at the same time
◆ STE in pericarditis MUST involve both chest and
limb leads.
◆ The supportive ECG features are contained in the
mnemonic below:
◆PERI-CAR-DI-TI-S
I
=
Inflammatory

36. PERI = PR Elevation, Revert Inferior
◆ PR elevation in lead aVR with ST depression
◆ PR depression in inferior leads and other (chest)
leads
PERI
=
PR
Elevation,
Revert
Inferior

37. CAR = Concave ST, Absent Reciprocal
◆ Concave ST elevation
◆ Absent reciprocal STD
◆No STD except in lead aVR
◆ Also absent pathological Q wave
CAR
=
Concave,
Absent
Reciprocal

38. DI = Degree ST, Inferior Lead
◆ Analyze the degree of STE height in inferior leads
(Leads II vs III)
◆ STE in lead II > III = Supports Pericarditis
◆ STE in lead III > II = Supports AMI
DI
=
Degree
ST,
Inferior
Lead

40. TI = T Inversion & Isoelectric ST
◆ T wave inversion in pericarditis occurs with ST
segment has returned to isoelectric line
◆ If TWI occurs while ST segment is still elevated =
Supports AMI
TI
=
T
Inversion
&
Isoelectric
ST

41. S = ST/T ratio in V6
◆ This ECG finding is highly specific for pericarditis:
◆ST/T ratio in lead V6 >0.25 (>25%)
◆ However, recall that ‘SpPIN’
◆ If the ratio is fulfilled, pericarditis is strongly
diagnosed.
◆ On the contrary, if it is not fulfilled = It does not
rule out pericarditis.
◆ One shall look for other supportive ECG changes
S
=
ST/T
ratio
in
V6

43. S.T.E.M.I1 Mnemonic
I component Diagnosis/Conditions
◆ I1 = Inflammatory ⚫ Pericarditis

44. PERI.CAR.DI.TI.S. Mnemonic
PERI.CAR.DI.TI.S. Components ECG Features
PERI
CAR
DI
TI
S
PR Elevation aVR, Revert
Inferior
Concave ST, Absent
Reciprocal
Degree ST, Inferior leads
T Inversion, Isoelectric ST
ST-T ratio in V6

45. List of conditions
1. AMI (STEMI)
2. Pericarditis
3. LVH
4. LBBB
5. Paced ventricular
rhythm
6. Prinzmetal angina
7. RVH
8. Posterior STEMI
9. Early Repolarization
10. Hyperkalemia
11. Cerebrovascular event
12. Hypothermia
13. Left ventricular
aneurysm
14. WPW syndrome
15. Takotsubo
CMP/syndrome
MyEZG
Workshop

46. FOR FURTHER
INQUIRY
email:
vit_ron@yahoo.com
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+60129089363
ANY QUESTION?
S.T.E.M.I. - Catching Mimics With Mnemonic
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