ROBERT FIELDS, DO

ST CHANGES

NONSPECIFIC ST-T WAVE CHANGES

Electrolyte abnormalities Post-cardiac surgical state Anemia Fever Acidosis or alkalosis Catecholamines Drugs Acute abdominal process Endocrine abnormalities Metabolic changes Cerebrovascular accidents Diseases such as myocarditis, pericarditis, cardiomyopathy, pulmonary

emboli, infections, amyloidosis, systemic diseases, lung diseases

ST-T WAVE CHANGES ASSOCIATED WITH SPECIFIC DISEASE STATES — Specific patterns of ST-T wave changes may be seen in

association with various disease states.

Specific patterns of ST-T wave changes may be seen in association with various disease states.

Ischemia Myocardial Injury V1-V2 — anteroseptal V3-V4 — anteroapical V5-V6 — anterolateral 1, aVL — lateral 2, 3, aVF — inferior

Pericarditis LVH Intraventricular conduction

Delays (RBBB, LBBB)’ Aneurysm Persistent Juvenile t-wave

pattern Shortened QT intervals, ie

Early Repolarization

PRESENTED BY ROBERT FIELDS, DO DIRECTOR/CHAIRMAN OF SAINT JOSEPH

MERCY LIVINGSTON EMERGENCY DEPARTMENT

ST-Segment Elevation in Conditions Other Than Acute Myocardial Infarction

Kyuhyun Wang, M.D., Richard W. Asinger,

M.D., and Henry J.L. Marriott, M.D.

Normal/Schnormal

Tracing 1 in Figure 1 is an example of normal ST-segment elevation.

In a study of 6014 healthy men in the U.S. Air Force who were 16 to 58 years old,

91 percent had ST-segment elevation of 1 to 3 mm in one or more precordial leads.6

The elevation was

most common and marked in lead V2.

The prevalence of ST-segment elevation of at least 1 mm in one or more of leads V1 through V4 was 93 percent in the men who were 17 to 24 years old.7

Wang K et al. N Engl J Med 2003;349:2128-2135

Electrocardiograms Showing Normal ST-Segment Elevation and Normal Variants

Now the fun begins….

Normal Variant

In some healthy young people, especially in black men, the ST segment is elevated by 1 to 4 mm in the midprecordial leads as a normal variant.

This pattern is commonly referred to as early repolarization,8 even though clinical studies have failed to demonstrate an earlier-than-normal onset of ventricular recovery.9

Wang K et al. N Engl J Med 2003;349:2128-2135

Electrocardiograms Showing Normal ST-Segment Elevation and Normal Variants

Now the fun begins….

Early Repolarization

“Early repolarization is characterized by…elevation at point where depol meets repol

This is known as J – point elevation

The elevation is carried into ST segment

Tracing 2 in Figure 1 is an example of the early-repolarization pattern.

In most instances of early repolarization, the ST-segment elevation is most marked in V4, there is a notch at the J point (the junction between the QRS complex and the ST segment), and the ST segment is concave.

The T waves are tall and are not inverted

Wang K et al. N Engl J Med 2003;349:2128-2135

Electrocardiograms Showing Normal ST-Segment Elevation and Normal Variants

Now the fun begins….

What do you think about tracing three?

Difficult situation on this one particularly if this person is having chest pain…

Combination of Early Repolarization and persistent juvenile t-wave pattern

Any major group excluded…yes

In contrast, about 20 percent of normal electrocardiograms from women had ST-segment elevation of 1 mm or more, and this prevalence remained unchanged regardless of the women's ages.

So how would you describe the first one…

Dr Z dictating on patient…..the 12 lead EKG reveals…

“A male pattern variant with associated non-pathological ST elevation of 1mm in lead V2”

Since the majority of men have ST elevation of 1 mm or more in precordial leads, it is a normal finding, not a normal variant, and is designated as a male pattern

What do you think about “early repolarization” ?

BenignMalignantI don’t knowI don’t care (unless of course I have it…)

NEJM May 2008

Volume 358:2016-2023 May 8, 2008 Number 19 NEJM Sudden Cardiac Arrest Associated with Early Repolarization

Michel Haïssaguerre, M.D., Nicolas Derval, M.D., Frederic Sacher, M.D., Laurence Jesel, M.D., Isabel Deisenhofer, M.D., Luc de Roy, M.D., Jean-Luc Pasquié, M.D., Ph.D., Akihiko Nogami, M.D., Dominique Babuty, M.D., Sinikka Yli-Mayry, M.D., Christian De Chillou, M.D., Patrice Scanu, M.D., Philippe Mabo, M.D., Seiichiro Matsuo, M.D., Vincent Probst, M.D., Ph.D., Solena Le Scouarnec, Ph.D., Pascal Defaye, M.D., Juerg Schlaepfer, M.D., Thomas Rostock, M.D., Dominique Lacroix, M.D., Dominique Lamaison, M.D., Thomas Lavergne, M.D., Yoshifusa Aizawa, M.D., Anders Englund, M.D., Frederic Anselme, M.D., Mark O'Neill, M.D., Meleze Hocini, M.D., Kang Teng Lim, M.B., B.S., Sebastien Knecht, M.D., George D. Veenhuyzen, M.D., Pierre Bordachar, M.D., Michel Chauvin, M.D., Pierre Jais, M.D., Gaelle Coureau, Ph.D., Genevieve Chene, Ph.D., George J. Klein, M.D., and Jacques Clémenty, M.D.

Tracings We Will See

LVHLBBBPericarditisHyperkalemiaAMIBrugada Syndrome

Wang K et al. N Engl J Med 2003;349:2128-2135

Electrocardiograms Showing ST-Segment Elevation in Various Conditions

LVH

Recall Criteria for LVHThe two most important pressure overload

states are systemic hypertension and aortic stenosis.

The major conditions associated with left ventricular volume overload are aortic or mitral valve regurgitation and dilated cardiomyopathy.

LVH

Cornell voltage criteria — These more recent criteria are based upon echocardiographic correlative studies designed to detect a left ventricular mass index >132 g/m2 in men and >109 g/m2 in women [14].

For men: S in V3 plus R in aVL >2.8 mV (28 mm)

For women: S in V3 + R in aVL >2.0 mV (20 mm)

LBBB

These secondary ST–T changes are shifted to the opposite direction from the major component of the QRS complex (i.e., discordant). When these changes are concordant, they are specific for acute myocardial infarction.

Concordant = MI, Disconcordant = LBBB but does not exclude MI

Wang K et al. N Engl J Med 2003;349:2128-2135

Electrocardiograms Showing ST-Segment Elevation in Various Conditions

Look at 2 and 5, similarity noted

How about tracing three?

Look specifically at the limb lead

What do you see?PR depression?ST elevation?Pericarditis

Pericarditis

Diffuse pericarditis involves not only the subepicardial layer of the ventricular wall, which is responsible for the ST-segment

elevation, but also the subepicardial layer of the atrial wall, which causes an atrial injury pattern.

Wang K et al. N Engl J Med 2003;349:2128-2135

Electrocardiograms Showing ST-Segment Elevation in Various Conditions

Focus on tracing four…

Hyperkalemia

Even though the pseudoinfarction pattern of hyperkalemia is well known, the ST-segment elevation is so striking at times that one cannot help agonizing over the possibility of coexistent acute infarction.

How would you know…echocardiogram? Ok how about a potassium level and treat it stat…you will see the changes immediately.

Tracings five and six…

STEMI

Ok, why….

Brugada Syndrome

The syndrome has been linked to mutations in the cardiac sodium-channel gene,25

Which result in a depression or a loss of the action-potential dome in the right ventricular epicardium but not in the endocardium, creating a transmural voltage gradient that is responsible for the ST-segment elevation in the right precordial leads and the genesis of ventricular fibrillation.26,27,28

The Brugada syndrome is characterized by electrocardiographic abnormalities, and diagnostic criteria have been proposed

Recognition is imperative… Idiopathic ventricular fibrillation

References

ST-Segment Elevation in Conditions Other Than Acute Myocardial InfarctionKyuhyun Wang, M.D., Richard W. Asinger, M.D., and Henry J.L. Marriott, M.D.

Sudden Cardiac Arrest Associated with Early RepolarizationMichel Haïssaguerre, M.D., Nicolas Derval, M.D., Frederic Sacher, M.D., Laurence Jesel, M.D., Isabel Deisenhofer, M.D., Luc de Roy, M.D., Jean-Luc Pasquié, M.D., Ph.D., Akihiko Nogami, M.D., Dominique Babuty, M.D., Sinikka Yli-Mayry, M.D., Christian De Chillou, M.D., Patrice Scanu, M.D., Philippe Mabo, M.D., Seiichiro Matsuo, M.D., Vincent Probst, M.D., Ph.D., Solena Le Scouarnec, Ph.D., Pascal Defaye, M.D., Juerg Schlaepfer, M.D., Thomas Rostock, M.D., Dominique Lacroix, M.D., Dominique Lamaison, M.D., Thomas Lavergne, M.D., Yoshifusa Aizawa, M.D., Anders Englund, M.D., Frederic Anselme, M.D., Mark O'Neill, M.D., Meleze Hocini, M.D., Kang Teng Lim, M.B., B.S., Sebastien Knecht, M.D., George D. Veenhuyzen, M.D., Pierre Bordachar, M.D., Michel Chauvin, M.D., Pierre Jais, M.D., Gaelle Coureau, Ph.D., Genevieve Chene, Ph.D., George J. Klein, M.D., and Jacques Clémenty, M.D.

Other Resources including “uptodate.com”

Wang K et al. N Engl J Med 2003;349:2128-2135

Electrocardiograms from a Patient with Massive Pulmonary Embolism Who Had a Normal Coronary Angiogram (Tracing 1) and a Patient with Transient ST-Segment Elevation Immediately

after Direct-Current (DC) Countershock to the Precordium (Tracing 2)