ST segment elevation
(Redirected from ST-elevation)
Background
- Its presence must be explained (there is no "nonspecific ST elevation")
- Not specific only to STEMI
Clinical Features
- Depends on underlying etiology
Differential Diagnosis
ST Elevation
- Cardiac
- ST-segment elevation myocardial infarction (STEMI)
- Post-MI (ventricular aneurysm pattern)
- Previous MI with recurrent ischemia in same area
- Wellens' syndrome
- Coronary artery vasospasm (eg, Prinzmetal's angina)
- Coronary artery dissection
- Pericarditis
- Myocarditis
- Aortic dissection in to coronary
- Left ventricular aneurysm
- Left ventricular pseudoaneurysm
- Early repolarization
- Left bundle branch block
- Left ventricular hypertrophy (LVH)
- Myocardial tumor
- Myocardial trauma
- RV pacing (appears as Left bundle branch block)
- Brugada syndrome
- Takotsubo cardiomyopathy
- AVR ST elevation
- Other thoracic
- Metabolic
- Drugs of abuse (eg, cocaine, crack, meth)
- Hyperkalemia (only leads V1 and V2)
- Hypothermia ("Osborn J waves")
- Medications
Evaluation
Early Repolarization versus STEMI
- Early Repolarization suggested by:
- ST elevation <4mm
- Notched J point
- Concave or saddle-back ST morphology
- No reciprocal changes
- Consistent over short term
- Young patient without risk factors
LVH versus STEMI
- Difficult to exclude MI in patient with LVH (patients with LVH are already at risk for MI)
- Best aid is prior ECG or serial ECGs
LBBB versus STEMI
STEMI
- ST elevation in those leads that reflect the distribution of a single coronary artery
- RCA: II, III, aVF (inferior)
- LAD: V1-V4 (antero-septal)
- Circumflex: V5-V6, I, aVL (lateral)
- Dominant left circulation: infero-lateral
- ST morphology
- Concave up versus convex
- Convex has Sp 97%, Sn 77%
- Concave up versus convex
- Look for reciprocal ST depression
- 35% of anterior STEMI have ST depression in inferior leads
- 80% of inferior STEMI have ST depression in anterior leads
- However, may represent reciprocal changes OR posterior STEMI
Reciprocal Changes
- Anterior STEMI
- Reciprocal ST-segment depression in at least one of leads II, III, aVF
- Occurs in 40-70% of cases
- Inferior STEMI
- Reciprocal ST-segment depression usually present in I, aVL; often in V1-V3
- Occurs in 56% of cases
- Posterior STEMI
- Reciprocal ST-segment depression in V1-V4
- Differentiate from inf STEMI reciprocal depression based on upright T waves, posterior leads showing STEMI
- Often associated with ST-segment elevation in II, III, aVF (inferior involvement)
- Reciprocal ST-segment depression in V1-V4
STEMI Stages of Development
Stage | Duration | Timing | Finding | ECG |
1 | 30min - hours | Hyperacute T waves
|
Normalizes in days, weeks, or months | |
2 | Minutes - hours | ST segment elevation
|
ST segment resolution occurs over 72hrs; completely resolves within 2-3wks | |
3 | Within 1hr; completed within 8-12hr | Q waves | Persist indefinitely in 70% of cases |
Management
Disposition
See Also
References
- ↑ Gibbons RJ, Balady GJ, Bricker JT, Chaitman BR, Fletcher GF, Froelicher VF, Mark DB, McCallister BD, Mooss AN, O'Reilly MG, Winters WL Jr, Gibbons RJ, Antman EM, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Hiratzka LF, Jacobs AK, Russell RO, and Smith SC Jr. ACC/AHA 2002 guideline update for exercise testing: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). Circulation 2002 Oct 1; 106(14) 1883-92. pmid:12356646.