STEMI equivalents

1. STEMI Equivalents
DR. ANTON LABEEB

2. Case 1:
 A 41 years old male admitted three hours after the onset of
typical angina associated with profuse sweating. The patient
was a heavy smoker (40 PA) and he had no other known
cardiovascular risk factors, but he had a positive family
history for cardiovascular disease. Upon admission the
patient was in severe pain, but otherwise stable.

3.  The first and the second troponin I values taken one hour and four hours
from the onset of the pain were negative. The patient was initially
managed conservatively on pharmacological treatment with
disappearance of the pain after a 3 μg/min dose of i.v. nitroglicerin was
initiated.

4.  An echocardiogam was performed and revealed akinetic interventricular
septum, apex and apical inferior wall with a global ejection fraction of 40% and a
mild mitral regurgitation.

6. De Winter T Waves
upsloping
ST segment
depression with tall
and peaked
symmetric T waves
in the precordial
leads V3-V4

8. sinus rhythm, 80 bpm and 2 mm upsloping
ST segment depression with tall and peaked
symmetric T waves in the precordial leads V3-V4

9. De Winter T Waves
 Key diagnostic features include ST depression and peaked T waves in
the precordial leads.
 The de Winter pattern is seen in ~2% of acute LAD occlusions and is under-
recognised by clinicians.
 Unfamiliarity with this high-risk ECG pattern may lead to under-treatment (e.g.
failure of cath lab activation), with attendant negative effects on morbidity and
mortality.

10. Background
 The de Winter ECG pattern was first reported in a 2008 case series by de Winter
RJ, Verouden NJ, Wellens HJ et al. They observed this ECG pattern in 30 / 1532
patients with acute LAD occlusions (2% of cases).
 Verounden and colleagues replicated this finding in a 2009 case series. They
found a de Winter ECG pattern in 35 / 1890 patients requiring PCI to the LAD (2%
of cases). Patients with the de Winter ECG pattern were younger, more likely to
be male and with a higher incidence of hypercholesterolaemia compared to
patients with a classic STEMI pattern.
 There is now growing evidence to suggest that the de Winter ECG pattern is
highly predictive of acute LAD occlusion.
 Some authors have proposed that the de Winter pattern should be considered a
“STEMI equivalent”, and that patients with chest pain and this ECG pattern should
receive emergent reperfusion therapy with PCI

11. Case 2 :
 67-year-old woman, smoker, non insulin-dependent diabetic,
hospitalized for episodes of repeated chest pains since
several days; ECG recorded in the absence of pain.

12. ECG:

13. Wellens syndrome: Type A – Biphasic, with
initial positivity and terminal negativity (25% of
cases)

14. Wellens syndrome:
Type A

16. Biphasic T waves due to
Hypokalaemia – T waves go
DOWN then UP

17. Case 3:
 A 75-year-old Caucasian man with medical history of
hypertension and peripheral arterial disease presented at the
emergency department, transported by the prehospital
emergency team, complaining of an intense chest pain,
which woke him up, with irradiation to the left upper limb and
diaphoresis. The patient denied nausea, vomiting,
palpitations and previous complaints of angina as well. It was
administered, during transport, sublingual nitroglycerine, with
resolution of the pain.

18. ECG:

19. Wellen syndrome :
Type B – Deeply and symmetrically inverted T
wave (75% of cases)

20. Wellen syndrome :
Type B – Deeply and symmetrically
inverted T wave

22. Diagnostic Criteria
 Rhinehart et al (2002) describe the following diagnostic criteria for Wellens
syndrome:
 Deeply-inverted or biphasic T waves in V2-3 (may extend to V1-6)
 Isoelectric or minimally-elevated ST segment (< 1mm)
 No precordial Q waves
 Preserved precordial R wave progression
 Recent history of angina
 ECG pattern present in pain-free state
 Normal or slightly elevated serum cardiac markers

23. Clinical Significance
 Wellens syndrome is a pattern of deeply inverted or biphasic T waves in V2-3,
which is highly specific for a critical stenosis of the left anterior descending
artery (LAD).
 Patients may be pain free by the time the ECG is taken and have normally or
minimally elevated cardiac enzymes; however, they are at extremely high risk for
extensive anterior wall MI within the next few days to weeks.
 Due to the critical LAD stenosis, these patients usually require invasive therapy;
do poorly with medical management; and may suffer MI or cardiac arrest if
inappropriately stress tested.

24. Case 4:
 A 66 years old male with a history of CAD who presents with 1.5 hours of chest
pain and is stable.

26. Posterior MI:
 Posterior MI is suggested by the following changes in V1-3:
 Horizontal ST depression
 Tall, broad R waves (>30ms)
 Upright T waves
 Dominant R wave (R/S ratio > 1) in V2

27. Posterior Myocardial Infarction
 Posterior infarction accompanies 15-20% of STEMIs, usually occurring in the
context of an inferior or lateral infarction.
 Isolated posterior MI is less common (3-11% of infarcts).
 Posterior extension of an inferior or lateral infarct implies a much larger area of
myocardial damage, with an increased risk of left ventricular dysfunction and
death.
 Isolated posterior infarction is an indication for emergent coronary reperfusion.
However, the lack of obvious ST elevation in this condition means that the
diagnosis is often missed.

30. ECG:

33. Case 5:

34. ST Elevation in aVR:
 Predictive Value of STE in aVR
 In the context of widespread ST depression + symptoms of myocardial
ischaemia:
 STE in aVR ≥ 1mm indicates proximal LAD / LMCA occlusion or severe 3VD
 STE in aVR ≥ 1mm predicts the need for CABG
 STE in aVR ≥ V1 differentiates LMCA from proximal LAD occlusion
 Absence of ST elevation in aVR almost entirely excludes a significant LMCA
lesion

35. Left main coronary artery (LMCA)
 Typical ECG findings with LMCA occlusion:
 Widespread horizontal ST depression, most prominent in leads I, II and V4-6
 ST elevation in aVR ≥ 1mm
 ST elevation in aVR ≥ V1

38. Case6:

40. Original Sgarbossa Criteria:
 The original three criteria used to diagnose infarction in patients with LBBB
are:
 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 -ve QRS complex
(score 2).
 These criteria are specific, but not sensitive for myocardial infarction. A total score
of ≥ 3 is reported to have a specificity of 90% for diagnosing myocardial infarction

42. 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.

48.  Positive Sgarbossa criteria in a patient with a ventricular paced rhythm:
 There is concordant ST depression in V2-5 (= Sgarbossa positive).
 The morphology in V2-5 is reminiscent of posterior STEMI, with horizontal ST
depression and prominent upright T waves.
 This patient had a confirmed posterior infarction, requiring PCI to a completely
occluded posterolateral branch of the RCA.

49. Case 7:
Tall T-Wave in Lead V1:
 While a normal EKG has a flat or inverted T-wave in lead V1, a New Tall T-wave
in lead V1 (NTTV1) can be an early sign of an ischemic hyperacute T-wave
 Upright T-wave in lead V1 is abnormal if:
 Height of upright T-wave in V1 taller than T-wave in V6, or
 A NEW, upright T-wave in V1 (compare to old EKG)

50. What is the significance of NTTV1?
 84.4% of patients in a series of 218 patients undergoing cardiac catheterization
had severe CAD (>75% stenosis)
 In patients with one vessel disease and NTTV1 >0.15mV, the lesion was:
 Left circumflex artery disease (44%)
 Right coronary artery (22%)
 Left anterior descending artery (2%)
 In patients with two vessel disease and NTTV1 >0.15mV, the lesions were:
 Left circumflex and right coronary artery disease (69%)
 Left anterior descending and left circumflex arteries (7%)
 Left anterior descending and right coronary arteries (17%)

54. Take Home Message
 Assuming a patient doesn’t have LVH or LBBB, a new, upright, tall T-wave in lead
V1 or a T-wave in lead V1 taller than V6 could signify hyperacute T-waves and
precede acute myocardial infarction. Remember to always compare to prior
EKGs.