Dr Cynthia Lim, Dr Peter Jordan, Dr Megan Robb Chest Pain and syncope Dr Cynthia Lim, Dr Peter Jordan, Dr Megan Robb

ACS - STEMI If there is ST elevation, it will be a STEMI if: Any ST dep except V1 or aVR (allowed in acute pericarditis) ST elevation III > II Horizontal or convex up ST elevation New Q waves

ACS - Pericarditis If ST elevation, pericarditis is more likely if: PR depression multiple leads Only reliably seen viral transient Low voltage and tachycardia = large pericardial effusion Use T-P as baseline (not P-P interval) If in doubt serial ECGs, seek opinion

Normal variant ST elevation ST elevation may occur as a normal variant and represents EARLY REPOLARISATION Seen in young adults and people of African descent ST elevation may also indicate other pathology BENIGN features Concave up morphology Large symmetrical T-waves Notch at R and S wave J-point elevation (point at where the ST segment begins.)

Pick the problem… (What’s it called?) Wellen’s Syndrome: Deep T-wave inversion or biphasic T-waves in the absence of pain in V2 – V5.

Wellen’s Syndrome Pattern of ECG T-wave changes which is associated with critical proximal LAD stenosis Presence may predict proximal LAD occlusion Found in patients with recent history of chest pain but changes present in absence of pain EST may be fatal Strong indicator for AG

30 yr old male with syncope Brugada Syndrome

Brugada Syndrome ECG Findings T-wave α types Three types ST elevation v1 – v3 > 2mm Complete or incomplete RBBB T-wave α types 1. Inverted 2. Biphasic 3. Upright

Brugada – Why do we care? Predisposition to polymorphic ventricular tachycardia Identification and treatment with AICD may prevent a young sudden cardiac death

25 year old with syncope on exercising Arrthymogenic RV cardiomyopathy/dysplasia - inverted T waves in leads V1 through V5. Arrowheads point to late RV activation, called an epsilon wave

When to refer cardiac syncope to ED All 2nd degree and 3rd degree heart blocks All trifascicular blocks All rapid AF >120 All SVTs in not terminated by Valsalva manouvre “funny looking” ST/T segments – discuss/fax Asymptomatic patients with WPW, ST changes can be referred to cardiology OPA