This document provides an overview of the various causes of ST elevation on electrocardiograms (ECGs). It discusses electrolyte abnormalities, left bundle branch block, early repolarization, ventricular hypertrophy, aneurysms, infections or injuries, Osborne waves, non-occlusive vasospasm, and Brugada syndrome. Specific ECG patterns are presented for each cause. Key factors to evaluate for each condition include the shape, amplitude, and distribution of ST segments and T waves. Scoring systems like Sgarbossa criteria are also described which can help determine if ST elevation in the setting of left bundle branch block is likely due to acute myocardial infarction.

1. ST ELEVATION
Thanh Phuong Nguyen YC (2011-2017)
CONCLUSION
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2. INTRO…
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3. CAUSE OF ST ELEVATION
• E - Electrolytes
• L – LBBB
• E – Early Repolarization
• V – Ventricular Hypertrophy
• A – Aneurysm
• T – Treatment
• I – Infection/ Injury
• O – Osbourn Waves
• N – Non Occlusive Vasospasm
• B – Brugada Syndrome08-05-2014 3HUE UNIVERSITY OF
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4. E-HYPERKALEMIA
• Classic ECG changes
Tall “peaked” T waves
Prolongation of PR Intervals
Absent P Waves
Wide QRS
Sinusoidal pattern or V-Tach/V-Fib
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6. Symmectrical T waves
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7. WHAT TO LOOK FOR
• Peaked T wave in leads with elevation. Ouch!!
• Symmetrical Up and Down strokes
• Often wide >120ms
• ST depression in orther leads
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8. L-LEFT BUNDLE BRANCH BLOCK
• What is normal for LBBB?
• Wide complex
• ST elevation
• Look for appropriate discordance (<5mm)
** Think Sgarbossa criteria
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12. Sgarbossa Criteria
STST ElevationElevation ≥ 1 mm and≥ 1 mm and
concordantconcordant with QRSwith QRS
complexcomplex
Score 5 pointsScore 5 points
Odds Ratio (OR) 25.2Odds Ratio (OR) 25.2
ST DepressionST Depression ≥ 1 mm in≥ 1 mm in
V1, V2, V3V1, V2, V3
Score 3 pointsScore 3 points
OR 6.0OR 6.0
STST ElevationElevation ≥ 5 mm and≥ 5 mm and
discordantdiscordant with QRSwith QRS
complexcomplex
Score 2 pointsScore 2 points
OR 4.3OR 4.3
Odds Ratio: a measure of the degree of association; for example, the odds of exposure among the cases compared
with the odds of exposure among the controls (www.cefpas.it/ebm/tools/glossary.htm)08-05-2014 12HUE UNIVERSITY OF
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13. STST ElevationElevation ≥ 1 mm and≥ 1 mm and concordantconcordant with QRSwith QRS
complexcomplex
ST DepressionST Depression ≥ 1 mm in V1, V2, V3≥ 1 mm in V1, V2, V3
STST ElevationElevation ≥ 5 mm and≥ 5 mm and discordantdiscordant with QRSwith QRS
complexcomplex
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14. • A total score of 3 or more suggests that
the patient is likely experiencing an AMI
based on the ECG crtieria
• With a score less than 3, the ECG
diagnosis is less certain requiring
additional evaluation
• Chan TC, Brady WJ, Harrigan RA et al. ECG in
Emergency Medicine and Acute Care. 1st ed.
Pennsylvania: Elsevier Mosby; 2005.
Sgarbossa Criteria
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15. E-EARLY REPOLARIZATION
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16. What to look for
• Notched J point in V3
• Concave upward ST segment
• Usually in V2-V5
• PR depression
• Usually less than 2mm elevation
• Not as peaked as hyperkalemic T waves, more rounded
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18. Notching or slurring
of J point
Concave
STE
Benign Early Repolarization
Large amplitude
T wave
PR depression
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19. • ECG characteristics:
1. STE <2 mm
2. Concavity of initial portion of the ST segment
3. Notching or slurring of the terminal QRS
complex
4. Symmetrical, concordant T wave of large
amplitude
5. Widespread or diffuse distribution of STE
o Does not demonstrate territorial distribution
1. Relative temporal stability
Benign Early Repolarization
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20. V-VENTRICULAR HYPERTROPHY
• Many different scoring method
• The most commonly used are S-L criteria
• ST depression & T wave inversion in the
left-side leads: “strain” pattern
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21. ECG Diagnostic Criteria for LVH
SensitivitySensitivity SpecificitySpecificity
Sokolow-Lyon IndexSokolow-Lyon Index
SV1 + (RV5 or RV6)>35mmSV1 + (RV5 or RV6)>35mm
2222 100100
Cornell Voltage CriteriaCornell Voltage Criteria
SV3+RaVL>28 mm (men), 20mm(women)SV3+RaVL>28 mm (men), 20mm(women)
4242 9696
R1 + SIII>25 mmR1 + SIII>25 mm 1111 100100
R in aVL> 11mmR in aVL> 11mm 1111 100100
Other Criteria include Romhilt and Estes Point Score
System
Chan TC, Brady WJ, Harrigan RA et al. ECG in EmergencyChan TC, Brady WJ, Harrigan RA et al. ECG in Emergency
Medicine and Acute Care. 1st ed. Pennsylvania: Elsevier Mosby;Medicine and Acute Care. 1st ed. Pennsylvania: Elsevier Mosby;
2005.2005.
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22. Left Ventricular Hypertrophy
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23. • The initial upsloping of the elevated ST
segment is frequently concave in LVH as
opposed to the more likely flat/convex ST
segment elevation in ACS
• The T wave is usually asymmetrical in
LVHas opposed to the symmetrical T
wave seen in coronary ischemia
ECG Changes of Left Ventricular
Hypertrophy vs AMI
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24. A-Aneurysm
• Extremely difficult to pick out!!!!
• Old MI mistake
• Look for RBBB with persistent ST elevation
• Deep Q waves
• Look at T/QRS ratio: Amplitude of T wave/the depth of
the S wave
high -> Acute MI
low -> LVA
*If there is one lead in V1-V4 with a T/QRS ratio>0.36 then
MI likely
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25. T-Treatment
• Not much to say here..take a breather..It
only get harder!!!!..
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26. INFECTION-INJURY
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27. Pericarditis
• ST elevation is present in all leads except
in aVR, DIII, V1
• ST depression in aVR
• PR depression
• No Reciprocal changes
• Have to look at the entire ECG
• Must rely on good patient interview, assessment
& history
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30. Acute Pericarditis – Four Classical
Stages
• First described by
Spodick et al
• Stage I
– first few days  2
weeks
– STE, PR depression
• Stage II
– last days  weeks
– Normalization of STE
• Stage III
– after 2-3 weeks, lasts
several weeks
– T wave inversion
• Stage IV
– lasts up to several
months
– gradual resolution of
T wave changes
Chan TC, Brady WJ, Pollack M. Electrocardiographic manifestations: acuteChan TC, Brady WJ, Pollack M. Electrocardiographic manifestations: acute
myopericarditis. J Emerg Med 1999; 17 (5):865-72.myopericarditis. J Emerg Med 1999; 17 (5):865-72.
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31. Stage 1 Pericarditis
PR
Depression
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32. Stage 2 Pericarditis
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33. Stage 3 Pericarditis
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34. • PR segment depression is usually
transient but may be the earliest and most
specific sign of acute myopericarditis
• Baljepally R, Spodick DH. PR-segment deviation
as the initial electrocardiographic response in
acute pericarditis. Am J Cardiol 1998; 81
(12):1505-6.
Pericarditis
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36. Variable Shapes Of ST Segment
Elevations in AMI
Goldberger AL. Goldberger: Clinical Electrocardiography: A Simplified
Approach. 7th ed: Mosby Elsevier; 2006.
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37. MI ST SEGMENTS
• Convex upward ST segments in 2
contigous leads
• Inappropriate concordant ST seg.
• Hyperacute T waves
Symmetrical
Rounded
BIG in relation to R wave
W I D E (# Narrow in hyperkalemia)
* Look for reciprocal changes
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39. Sgarbossa … Once again!!!
STST ElevationElevation ≥ 1 mm and≥ 1 mm and concordantconcordant with QRSwith QRS
complexcomplex
ST DepressionST Depression ≥ 1 mm in V1, V2, V3≥ 1 mm in V1, V2, V3
STST ElevationElevation ≥ 5 mm and≥ 5 mm and discordantdiscordant with QRSwith QRS
complexcomplex
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40. O-OSBORNE WAVE
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41. OSBORNE WAVE
• Are possitive deflections occuring at the
junction between the QRS and the ST
segment
• Typical of severe hypothermia
• Usually has large notch
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42. J WAVES
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43. N-NON OCCLUSIVE VASOSPASM
• Think Ischemia
• Resembling MI
• Moving on………..->
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44. BRUGADA SYNDROME
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