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Is He Having The Big One?. Sirous Partovi, M.D. Department of Emergency Medicine TTUHSC, El Paso. ECG #1- 68 year old with chest pain for 3 days. ECG #2- 66 year old man with 1 hour history of chest pressure. ECG #3- 39 year old AAM with chest pain, PMH HTN. - PowerPoint PPT Presentation
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Is He Having The Big One?
Sirous Partovi, M.D.
Department of Emergency Medicine
TTUHSC, El Paso
ECG #1- 68 year old with chest pain for 3 days
ECG #2- 66 year old man with 1 hour history of chest pressure
ECG #3- 39 year old AAM with chest pain, PMH HTN
ECG #4 - 62 year old with profuse diaphoresis and vomiting
ECG #5-72 year old male- PMH: CRF,a-fib presents with generalized weakness for
1 hour.
ECG #6- 45 year old female with onset of chest discomfort 2 hours
ago – PMH ?Cancer
ECG #7 – 50 year old man with crushing substernal chest pain for 30 minutes
ECG #8- 72 year old female with history of HTN found unconscious
ECG #9- 67 year old man with PMH of MI in respiratory failure due to
acute CHF
ECG #10- Chest pain radiating to the jaw in a 41 year old woman
Objectives Understand the etiology of chest pain Distinguish between Acute Coronary
events requiring thrombolysis and those that do not.
Recognize the more common conditions that may cause a pseudo-infarction pattern on ECG.
Chest Pain
2% of all ED visits 10-20% are diagnosed with AMI 1.7 million admissions to hospitals
annually $5 Billion spent on admitted patients
which AMI was subsequently ruled out in
Chest Pain- AMI
1.1 million cases of AMI annually 50% present to EDs 2%-8% rate of misdiagnosis 11,000 missed diagnosis of MI per
year 20% of money awarded in
malpractice cases
Differential Diagnosis of Chest Pain
Cardiac Ischemic
Angina Unstable
angina AMI
Non-ischemicPericarditisAortic dissectionValvularMyositis
Differential Diagnosis of Chest Pain
Non-cardiac Gastroesophageal Causes
GERD Esophageal spasm PUD Boerhaave’s Syndrome Cholecystitis
Differential Diagnosis of Chest Pain
Non-cardiac Non-gastroesophageal
Pneumothorax Pulmonary embolism Musculoskeletal Somatoform disorders
Chest Pain-Diagnosis
History and Physical ECG Cardiac serum markers
AMI- World Health Organization (WHO)
Definition A combination of two of three
characteristics: Typical symptoms (i.e., ischemic-type
chest discomfort) A rise and fall in serum cardiac markers Typical ECG pattern involving the
development of Q waves
Acute MI - History 70%-80% present with ischemic type
CP Less than 25% of patients admitted to
hospital with ischemic-type CP are diagnosed with AMI
Unusual symptoms for AMI Elderly Women Diabetics
Features of H&P That Increase the Probability of AMI
Panju et al, JAMA. 1998;280:1256-1263
History and Physical LR Chest pain radiating to both arms 7.1 Third heart sound 3.2 Hypotension 3.1 Chest pain radiating to right shoulder 2.9
Likelihood Ratio
Positive LR Odds that a patient with a positive
test result has the target disorder Pos LR= Sensitivity/(1-Specificity)
Negative LR Odds that a patient with a negative
test result has the target disorder Neg LR= (1-Sensitivity)/Specificity
Historical Features That Decrease the Probability of AMI
Panju et al, JAMA. 1998;280:1256-1263
Quality of Chest Pain LR Pleuritic 0.2 Sharp or stabbing 0.3 Positional 0.3 Reproduced by palpation 0.2-0.4
ECG evolution in Q-wave Myocardial Infarction
Tall peaked T-waves ST-segment elevation Appearance of abnormal Q wave Decrease of ST-segment elevation
with the beginning of T-wave inversion Isoelectric ST-segment with
symmetrical T-wave inversion
Tall T- Waves
The earliest sign of AMI Due to subendocardial ischemia Within minutes or hours after the
onset of chest pain Transient Most ECGs fail to show this pattern
ECG evolution in Q-wave Myocardial Infarction
Tall peaked T-waves ST-segment elevation Appearance of abnormal Q wave Decrease of ST-segment elevation
with the beginning of T-wave inversion
Isoelectric ST-segment with symmetrical T-wave inversion
ST-Segment Elevation
The most common early ECG sign STE - specificity 91% , sensitivity 46% Mortality increases with the number of
ECG leads showing ST elevation STE decreases in the first 7-12 hours STE resolves within 2 weeks in 90% of
IWMI, but only in 40% of anterior MI
Reciprocal ST-Segment Depression
Seen in up to 82% Marked early, 50% resolve within 24
hours Due to reciprocal electrical alteration Increases specificity of AMI to 99% Seen in 72% of IWMI Indicative of:
Larger AMI Lower ventricular ejection fraction Higher mortality
ECG evolution in Q-wave Myocardial Infarction
Tall peaked T-waves ST-segment elevation represents a
stage beyond ischemia -i.e. injury Appearance of abnormal Q-wave Decrease of ST-segment elevation
with the beginning of T-wave inversion
Isoelectric ST-segment with symmetrical T-wave inversion
Abnormal Q-Waves
Most commonly presents while ST-segment still elevated
12-20% of Q-waves do not persist CHF is more common with
persistent Q-waves
ECG evolution in Q-wave Myocardial Infarction
Tall peaked T-waves ST-segment elevation Appearance of abnormal Q wave Decrease of ST-segment elevation
with the beginning of T-wave inversion
Isoelectric ST-segment with symmetrical T-wave inversion
ECG evolution in Q-wave Myocardial Infarction
Tall peaked T-waves ST-segment elevation represents a
stage beyond ischemia -i.e. injury Appearance of abnormal Q wave Decrease of ST-segment elevation
with the beginning of T-wave inversion
Isoelectric ST-segment with symmetrical T-wave inversion
Criteria for Thrombolysis
ST elevation (greater than 1 mm in two or more contiguous leads), time to therapy 12 hours or less, age less than 75 years.
Bundle branch block (obscuring ST-segment analysis) and history suggesting acute MI.
AMI Diagnosis- ECG
Factors Influencing ECG Interpretation
Clinical observation of the patient Knowledge of clinical data Training and experience of interpreter
AMI Diagnosis- ECG
Gjorup et al, J Intern Med. 1992; 231: 407-412
16 IM residents read 107 ECGs Looking for signs indicative of AMI Disagreement in 70% of the cases
AMI Diagnosis- ECG
Willems et al, NEJM. 1991; 325:1767-1773
8 cardiologists interpreted 1220 ECGS High interobserver agreement - of
0.67 125 ECGs read twice
Different diagnosis for 10%-23% of ECGs
AMI Diagnosis- ECG
Massel et al. Am Heart J. 2000;140:221-6
3 cardiologists - 75 ECGs 2 occasions (within 7 days) First reading: Presence or absence
of thrombolysis eligibility criteria Second reading: criterion 1 plus the
subjective opinion that the changes represented acute transmural injury
AMI Diagnosis- ECG
Interobserver variability in thrombolytic therapy eligibility
Is there 1 mm ST elevation?
Does this represent an AMI?
Agreement kappa
Agreement kappa
Rater 1 vs 2 93.3 86.2 94.7 88.2
Rater 2 vs 3 88.0 75.8 94.7 88.0
Rater 1 vs 3 86.7 72.9 94.7 88.2
Overall
78.2
88.5
Errors in AMI
ECG of a patient who is otherwise eligible may be incorrectly interpreted as being nondiagnostic
ST-segment elevation may be erroneously interpreted as suggesting an AMI, resulting in the inappropriate overuse of thrombolysis
Errors in AMI – Missed Diagnosis
ECG of a patient who is otherwise eligible may be incorrectly interpreted as being nondiagnostic
ST-segment elevation may be erroneously interpreted as suggesting an AMI, resulting in the inappropriate overuse of thrombolysis
Errors in AMI - Missed Diagnosis
McCarthy et al, Ann Emerg Med.1993;22:5795-82 Rate of missed AMI among 6 NE hospitals 1050 patients with AMI
1.9% misdiagnosed 25% of the patients with missed AMI had
STE of at least 1 mm Death or severe complications in 25% of
pts
Errors in AMI - Missed Diagnosis
Pope et al, NEJM 2000;342:1163-70
10,689 patients, 10 hospitals (ACI-TIPI trial)
17% had acute cardiac ischemia (ACI) 8% AMI 9% UA
6% stable angina 21% other cardiac diagnosis 55% noncardiac diagnosis
Errors in AMI – Missed Diagnosis
Pope et al
Of 894 AMI patients, 19 (2.1%) was missed
8 (47%) had one of the following ECG readings: LVH, LBBB, BER, pericarditis
7 (41%) minor ST segment abnormality with <1mm of ST segment deviation
14 of 19 had NQWMI
Errors in AMI – Missed Diagnosis
Brady et al, AEM, April 2001 11 ECGs with STE 45 yo male with HTN, DM and chest
pain 458 EPs
Errors in AMI – Missed Diagnosis
Brady et al, AEM, April 2001 Overall rate of correct
Errors in AMI
ECG of a patient who is otherwise eligible may be incorrectly interpreted as being nondiagnostic
ST-segment elevation may be erroneously interpreted as suggesting an AMI, resulting in the inappropriate overuse of thrombolysis
Errors in AMI - Over Diagnosis
Lee et al, Ann Int Med 1989;110:957-62.
No AMI in 25% of patients with acute chest pain and ST-segment elevation
For every 8 patients appropriately treated with a thrombolytic agent 1 or 2 will be treated unnecessarily
Errors in AMI-Over Diagnosis
Sharkey et al, Am J Cardiol 1994;73:550-3
93 patients with chest pain receiving thrombolytic therapy, AMI did not occur in 10 (11%) LVH- 30% BER- 30% IVCD- 30%
Impact of Errors
Bleeding consequences Life-threatening bleed- 0.4% Moderate bleed- 5%
Not treating an eligible thrombolysis candidate
Financial consequences Missed AMI is the leading cause of
malpractice loss in the ED setting
Causes of ST Segment Elevation
Cardiac Acute myocardial infarction Variant (Prinzmetal's) angina Acute pericarditis Left ventricular aneurysm Left ventricular hypertrophy Bundle branch blocks Benign Early repolarization
Causes of ST Segment Elevation
Metabolic Hyperkalemia Hypothermia (Osborne or "J" waves) Hyperventilation
Causes of ST Segment Elevation
Miscellaneous Acute abdominal disorders
(pancreatitis, cholecystitis, peritonitis) Central nervous system hemorrhage Medications (type I anti-arrhythmic
agents, isoproterenol) Body habitus Idiopathic
Localization of Acute MI
LOCATION ECG LEADS INVOLVED
PROBABLE ARTERY INVOLVED
Anteroseptal V1, V2 Proximal LAD septal perforator
Anterior V2, V4 LAD or its branches
Anterolateral V4- V6, I, aVL
Mid LAD or circumflex
Extensive Anterior
V1-V6 Proximal LAD
Inferior II,II,aVF RCA, circumflex, distal LAD
High lateral I, aVL Circumflex or branch of LAD
Posterior V1, V2 Posterior descending
Right ventricle V1, rV3- rV4 RCA
ECG #1- 32 year old with chest pain at a party
Anterolateral MI
Anterolateral MI - II
Anterolateral MI - III
65 year old with acute chest pain
Anterior MI
Acute Anterior MI
Acute Anteroseptal MI
Acute Anterior MI
Acute Anteroseptal MI
53 year old with severe light headedness, nausea, diaphoresis, and upper abdominal pain. Bloods pressure
85/palp.
Acute Inferoposterior MI
R
R
R
R
R
Acute Lateral MI
ECG #4 - 62 year old with profuse diaphoresis and vomiting
ECG #7 – Acute Posterior MI - Old inferior MI
Inferior MI
(MR# 866159) -77 year old male with chest pain and palpitation
Anterior MI
LVH with ST-T Wave Changes
Left Ventricular Hypertrophy
Definition ECG diagnosis: based on the increase of
the QRS voltage Possible LVH - only voltage evidence of LVH Definite LVH - voltage evidence of LVH
associated with ST-T wave changes (strain) Strain pattern – characterized by
downsloping ST depression with asymmetric, biphasic, or inverted T wave (occurs in 70% of cases)
LVH With Strain and CAD
50% prevalence of demonstrated CAD in asymptomatic hypertensive patients with LVH and strain vs. 4% general population
60% of patients with LVH and strain had reversible perfusion defects on Thallium scintigraphy
LVH
ECG is 93-96% specific and 12-29% sensitive in diagnosing LVH
Echocardiography- 86% specificity and 100% sensitivity for diagnosis of LVH
LVH
Otto LA et al, Ann Emerg Med 1994;23:17-24
Prehospital study of adult chest pain patients with STE
Majority did not have AMI LVH and LBBB were most common
LVH
Brady WJ, J Emerg Med
STE resulted from AMI in only 15% LVH was the most frequent cause
of this STE (30%)
LVH
Larsen et al, J Gen Intern Med 1994;9:666-673
10% of patients diagnosed in the ED with acute ischemic heart disease have LVH
Only 26% of these patients were found to have unstable angina or AMI
Physicians incorrectly interpreted the ECG more than 70% of the time
LVH by Voltage Only
Cornell Criteria- RaVL+SV3 >24 mm in males >20 mm in female
LVH by Voltage Only
Other commonly used voltage-based criteria Precordial leads (one or more)
RV5 or V6 + SV1 >35 mm if age> 30 years >40 mm if age 20-30 years >60 mm if age 16-19 years
Maximum R wave + S wave in precordial leads >45 mm
RV5 > 26 mm RV6> 20mm
LVH by Voltage Only
Other commonly used voltage criteria Limb leads (one or more)
RaVL >12 mm RI + SII >26 mm RI >14 mm SaVR >15 mm RaVF >21 mm
LVH by Voltage
RV5+SV1=43mm
RV5= 37mm
LVH by Both Voltage and ST-T Segment Abnormalities
Voltage criteria for LVH ST-T segment abnormalities
ST segment and T wave deviation opposite in direction to the major deflection of QRS
ST segment depression in leads I, aVL, III, aVF +/- V4-V6
Subtle ST elevation (1-2 mm) in leads V1-V3
Inverted T waves in leads I, aVL, V4-V6 Prominent or inverted U waves
LVH by Both Voltage and ST-T Segment Abnormalities
Voltage criteria for LVH ST-T segment abnormalities
ST segment and T wave deviation opposite in direction to the major deflection of QRS
ST segment depression in leads I, aVL, III, aVF +/- V4-V6
Subtle ST elevation (1-2 mm) in leads V1-V3 Inverted T waves in leads I, aVL, V4-V6 Prominent or inverted U waves
LVH by Both Voltage and ST-T Segment Abnormalities
Voltage criteria for LVH ST-T segment abnormalities
ST segment and T wave deviation opposite in direction to the major deflection of QRS
ST segment depression in leads I, aVL, III, aVF +/- V4-V6
Subtle ST elevation (1-2 mm) in leads V1-V3
Inverted T waves in leads I, aVL, V4-V6 Prominent or inverted U waves
LVH by Both Voltage and ST-T Segment Abnormalities
Voltage criteria for LVH ST-T segment abnormalities
ST segment and T wave deviation opposite in direction to the major deflection of QRS
ST segment depression in leads I, aVL, III, aVF +/- V4-V6
Subtle ST elevation (1-2 mm) in leads V1-V3 Inverted T waves in leads I, aVL, V4-V6Prominent or inverted U waves
Romhilt and Estes LVH Point Score System
QRS Voltage – 3 points for the presence of any 1 criteria R or S in limb leads 20 mm S in V1 or V2 30 mm R in V5 or V6 30 mm
Typical ST-T repolarization abnormality Without digitalis – 3 points With digitalis – 1 point
LAD - 30° or more – 2 points QRS duration 0.09 sec – 1 point ID V5-6 0.05 sec – 1 point LAE – 3 points
LVH With ST-T Abnormalities
R in I = 15mm
S in aVR > 14mm
RV5>26mmRV5+SV1=65mm
R in aVL + S in V3 >24mm
LVH With ST-T Abnormalities
34 year old AAM with chest pain-No PMH
Benign Early Repolarization
First described in 1936 by Shipley A normal variant- 1% general
population Common in athletes BER-in adult ED chest pain patients
~13% BER is seen on ECGs 23-48% of adult
ED chest pain patients who have used cocaine
Benign Early Repolarization
Mean age - 39 (16-80) Most commonly less than 50 years
of age- older than 70 years(3.5%) Seen in men much more often
than women
ECG Criteria For BER Elevated take-off of ST segment at the J point Upward concavity of the initial portion of the
ST segment Notching or slurring on downstroke of R wave Symmetric, concordant T waves of large
amplitude Widespread or diffuse distribution of ST
segment elevation on the ECG - most commonly in leads V2-V5, sometimes in inferior leads
No reciprocal ST segment change relative temporal stability
J point elevation- less than 3.5 mm ST segment appears as if it has been
lifted evenly upward STE is less than 2 mm in 80-90% Only 2% of cases STE is greater than 5
mm.
J point
ECG Criteria For BER Elevated take-off of ST segment at the J point Upward concavity of the initial portion of the
ST segment Notching or slurring on downstroke of R wave Symmetric, concordant T waves of large
amplitude Widespread or diffuse distribution of ST
segment elevation on the ECG - most commonly in leads V2-V5, sometimes in inferior leads
No reciprocal ST segment change relative temporal stability
Upward concavity
ECG Criteria For BER Elevated take-off of ST segment at the J point Upward concavity of the initial portion of the
ST segment Notching or slurring on downstroke of R wave Symmetric, concordant T waves of large
amplitude Widespread or diffuse distribution of ST
segment elevation on the ECG-most commonly in leads V2-V5, sometimes in inferior leads
No reciprocal ST segment change relative temporal stability
Tall symmetric T wave
ECG Criteria For BER Elevated take-off of ST segment at the J point Upward concavity of the initial portion of the
ST segment Notching or slurring on downstroke of R wave Symmetric, concordant T waves of large
amplitude Widespread or diffuse distribution of ST
segment elevation on the ECG - most commonly in leads V2-V5, sometimes in inferior leads
No reciprocal ST segment change relative temporal stability
Benign Early Repolarization (BER)
Acute Pericarditis
Acute Pericarditis
Stage 1- Concave up ST segment elevation
Stage 2- ST segment normal, flattening of the T waves
Stage 3- T wave inversion without Q wave formation
Stage 4- Normalization of ECG
Acute Pericarditis- Other ECG Clues
Sinus tachycardia PR depression early Low voltage QRS Electrical alternans if pericardial
effusion
BER or Pericarditis ST segment elevation in the two syndromes
is similar PR segment in pericarditis is often depressed ST segment elevation in acute pericarditis
tends to be widespread across the ECG T waves in pericarditis frequently is of normal
amplitude and morphology, whereas the T wave in BER is frequently altered
The ratio of the ST segment elevation to the height of the T wave (ST/T) is also a helpful guide; a ratio greater than 0.25 in lead V6 strongly suggests pericarditis
BER or Pericarditis ST segment elevation in the two syndromes
is similar PR segment in pericarditis is often depressed ST segment elevation in acute pericarditis
tends to be widespread across the ECG T waves in pericarditis frequently is of normal
amplitude and morphology, whereas the T wave in BER is frequently altered
The ratio of the ST segment elevation to the height of the T wave (ST/T) is also a helpful guide; a ratio greater than 0.25 in lead V6 strongly suggests pericarditis
BER or Pericarditis ST segment elevation in the two syndromes
is similar PR segment in pericarditis is often depressed ST segment elevation in acute pericarditis
tends to be widespread across the ECG T waves in pericarditis frequently is of normal
amplitude and morphology, whereas the T wave in BER is frequently altered
The ratio of the ST segment elevation to the height of the T wave (ST/T) is also a helpful guide; a ratio greater than 0.25 in lead V6 strongly suggests pericarditis
BER or Pericarditis ST segment elevation in the two syndromes
is similar PR segment in pericarditis is often depressed ST segment elevation in acute pericarditis
tends to be widespread across the ECG T waves in pericarditis frequently is of normal
amplitude and morphology, whereas the T wave in BER is frequently altered
The ratio of the ST segment elevation to the height of the T wave (ST/T) is also a helpful guide; a ratio greater than 0.25 in lead V6 strongly suggests pericarditis
Pericardial Effusion
Electrical Alternans
BER or AMI
ST-T wave complex waveform Reciprocal changes Evolutionary changes
BER or AMI
ST-T wave complex waveform Reciprocal changes Evolutionary changes
BER or AMI
ST-T wave complex waveform Reciprocal changes Evolutionary changes
LBBB
LBBB- ECG Criteria
Prolonged QRS duration( 0.12 sec) Delayed onset of intrinsicoid deflection in
leads I,V5, V6 Broad monophasic R waves in leads I, V5,
V6 Secondary ST & T wave changes opposite in
the direction to the major QRS deflection rS or QS complex in right precordial leads LAD may be present
LBBB- ECG Criteria
Prolonged QRS duration( 0.12 sec) Delayed onset of intrinsicoid deflection in
leads I,V5, V6 Broad monophasic R waves in leads I, V5,
V6 Secondary ST-T wave changes opposite in
the direction to the major QRS deflection rS or QS complex in right precordial leads LAD may be present
LBBB- ECG Criteria
Prolonged QRS duration( 0.12 sec) Delayed onset of intrinsicoid deflection in
leads I,V5, V6 Broad monophasic R waves in leads I, V5,
V6 Secondary ST & T wave changes opposite in
the direction to the major QRS deflection rS or QS complex in right precordial leads LAD may be present
QS
QS
rS
LBBB With MI
Fulfills criteria for LBBB Three criteria (Sgarbossa criteria)
with independent value for diagnosing AMI: ST elevation 1 mm concordant to the
major deflection of the QRS ST depression 1 mm in V1, V2, or V3 ST elevation 5 mm discordant with the
major deflection of the QRS
LBBB with Inferolateral MI
ECG #2- 66 year old man with history of LBBB and 1 hour history
of chest pressure
LBBB and AMI
LBBB and AMI
Sgarbossa criteria 96% specific Pos LR = 22 Neg LR = 0.8
RBBB
RBBB- ECG Criteria
QRS duration 0.12 sec Delayed onset of ID Increased amplitude of the R’ in V1-
V2 Wide, slurred S wave in leads I,V5,V6 Secondary ST-T abnormality
RBBB
Most patients with RBBB have CAD Many have no evidence of
underlying heart disease In patients with AMI, RBBB is
present in 3-7% of cases In uncomplicated RBBB, there
usually is little ST-segment displacement
AMI in The Presence of RBBB
RBBB does not interfere with the recognition of infarcts.
Even in presence of RBBB and either LAHB or LPHB, infarcts can be evaluated normally-EXCEPT True posterior MI
RBBB, Inferoposterior MI
RBBB+LAHB+Anterolateral MI
RBBB+LPHB+Anteroseptal
30 year old diabetic found unresponsive
Hyperkalemia
ECG #5-72 year old male, PMH: CRF and a-fib presents with generalized
weakness for 1 hour.
72 year old female found unresponsive
ECG and ICH
Most commonly SAH Altered autonomic tone as a
mechanism Abnormalities include
ST-segment elevation or depression Large, wide, upright , or inverted T waves Long QT interval Prominent U wave
ICH
70 year old asymptomatic man with PMH of MI
75 year old man found unresponsive on a park bench, on New Years Eve,
in Fargo…
Many causes of STE Features that increase likelihood of
AMI New STE New Q waves Any STE New LBBB