1. Concerning ST Elevations
Steve Lan
Aug 21,2003

2. Objective Concerning ST elevation vs benign ST changes
Remember: history, exam, labs, serial ECGS
Disclaimer: everyone has their own interpretation

3. Outline
Review
Differential
Examples and Comparisons
Conclusions

4. Tombstones

5. The Basics
Measure 0.04s after J point

6. Trouble: Sharp vs Diffuse J point

7. Differential Acute MI (15%) LVH with Strain (25%) LBBB (15%)
Early repolarization (12%)
LV aneurysm (3%)
Pericarditis (1%)
undefined (17%)
Brady WJ et al. Cause of ST Segment Abnormality in ED Chest Pain Patients. Am J Emerg Med 2001; 19:

8. Quick Examples Concave up = usually “good”
Concave down = usually “bad”

9. Additional information: T waves
As always look at the whole picture
reciprocal changes

10. Bad ST changes: Ischemia, Injury, Infarct

11. Evolution of Acute MI

12. Bad??

13. Not good??

14. Strain vs Infarction

15. LVH + Strain

16. Anteroseptal MI

17. Early Repolarization ST elevation in percordial concave up
may have reciprocal depression aVR
tall, peaked, assymetric T waves
younger (<50), good health
incidence 1-2%
Mehta, et al. Early Repolarization. Clin.Cardiol. 1999; 22, 59-65

18. Early Repolarization

19. Comparison

20. Pericarditis Stage 1 (day 2-3, lasting up to 2 wks) Concave up
diffuse ST elevation
ST/T wave ratio
> .25 in pericarditis
< .25 in early repolarization
no reciprocal changes

21. Pericarditis example

22. LBBB

23. Summary Not all ST elevations are equal Look for the company it keeps
Hx and physical
T waves, reciprocal changes
Concave up - usually ok
Concave down - usually bad

24. References
Brady WJ et al. Cause of ST Segment Abnormality in ED Chest Pain Patients. Am J Emerg Med 2001; 19:
12- Lead ECG: The Art of interpretation. Garcia, Holtz.