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

2. 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

3. 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

4. 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.)

5. 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.

6. 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

7. 30 yr old male with syncope
Brugada Syndrome

8. 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

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

10. 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

11. 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