ST Segment
Elevation
Differential Diagnosis
Introduction:
ST segment on the egg represents the
period between depolarisation and
depolarisation of the left ventricle.
In the normal state, ST segment is
isoelectric relative to PR segment
Measured at J point
Causes
Acute Myocardial infarction
Acute Pericarditis
Benign Early Repolarization
Left Bundle Branch Block with AMI
Left Ventricular Hypertrophy
Hyperkalemia
Brugada’s syndrome
Acute Myocardial Infarction
Minnesota Code:
Requires:
>1mm ST elevation in one or more of
leads I, II,III, aVL, aVF, V5, V6 or,
>2mm ST elevation in one or more of
leads V1-V4
Differentiate STE due to AMI and other
causes by:
Morphology
Distribution
Prominent Electrical Forces
QRS Width
Other Features
Morphology of the
ST Elevation
Variable shapes of STE in Ischemia
Variable shapes of STE in AMI
Morphology of STE
Concave shape STE - non AMI causes
AMI Causes: Usually demonstrate
convex/straight STE
Benign Early Repolarization
Benign Early Repolarization
ECG Characteristics:
STE < 2 mm
Concavity of the initial portion of the ST
segment
Notching /slurring of the terminal QRS
Complex
Symmetrical, concordant T wave of large
amplitude
Widespread/ diffuse distribution of STE
Distribution
Distribution
STE due to AMI usually demonstrates
regional or territorial pattern
. Anterior MI : V3-V4
. Septal MI : V2-V3
. Anteroseptal MI : V1/V2 - V4/V5
. Lateral MI : V5, V6
. Inferior MI : II,III,aVF
Diffuse STE - non AMI causes, eg Pericarditis
Pericarditis vs AMI
STE STE
- concave - flat or convex
-diffuse -terrritorial
PR depression Q wave
T wave inversion T wave inversion
- after ST - accompanies
normalised ST in AMI (co-
exist)
Pericarditis
PR segment depression is usually transient
but may be the earliest and most specific
sign of acute myopericarditis.
Acute Pericarditis - Four Classical Stages
Stage 1 Stage 3
First few days to 2 2 -3 weeks, lasts
weeks several weeks
STE, PR depression T wave inversion
Stage 2 Stage 4
Several days to weeks Lasts upto several
Normalization of STE months
Gradual resolution of T
wave changes
Stage 1 Pericarditis
PR depression
Stage 2 Pericarditis
Stage 3 Pericarditis
Pericarditis vs Benign Early Repolarization
Bot5h demonstrate initial concavity of the
up-sloping ST segment / T wave
PR depression in pericarditis; not seen in
BER.
ST/T ratio:
>0.25 Pericarditis
<0.25 BER
Brugada Syndrome
Autosomal Dominant
Asian men
Channelopathy: Defective Sodium channel
Arrhythmias during sleep, - (Increased
vagal tone - after heavy meal), fever
Brugada Syndrome
RBBB with RSR
pattern instead of
rSR pattern,
associated with
STE
Brugada Syndrome
Brugada Syndrome
QRS Width
Left Bundle Branch Block
In LBBB, the QRS complex is broad with
negative QS or rS complex in lead V1, and
may demonstrate STE
LBBB with STEMI??
Left Bundle Branch Block
Sgarbossa et [Link] a clinical
prediction rule to assist in the ECG
diagnosis of AMI in the setting of LBBB
using three specific ECG findings.
Score of 3 or more suggests that the
patient is probably having AMI based on
the ECG criteria
Sgarbossa’s Criteria
Prominent Electrical
Forces
Left Ventricular Hypertrophy
LVH vs AMI
The initial sloping of the ST segment is
frequently concave in LVH as opposed to
flat/convex ST segment in ACS
The T wave - usually asymmetrical in LVH,
symmetrical T wave in coronary ischemia
LVH vs AMI
LVH vs AMI
(A) ST-segment elevation in lead V2 is 25% of the R-S–wave
magnitude and 3 contiguous leads (V2 to V4) have ST-
segment elevation, consistent with a ST-segment elevation
myocardial infarction. There is left ventricular hypertrophy
by the Cornell criteria in this woman.
LVH vs AMI
B) Similar to the patient in A, this patient has an ST-
segment elevation/R-S–wave ratio 25% and ST-segment
elevation in 3 contiguous leads. There is left ventricular
hypertrophy based on the voltage in lead aVL.
LVH vs AMI
(C) In this patient with ST-segment changes in leads V1 to
V3, the ST-segment elevation/R-S–wave ratio is 25% and
there are T-wave inversions in lead V3. There is left
ventricular hypertrophy based on Sokolow-Lyon criteria.
Hyperkalemia
Hyperkalemia
Thank you
