Approach to ECGs - Ischemia

MI = Biomarkers + ECG or echo/angiogram findings

Pathologic Q - 1/3 height of QRS in 2 leads or 1 small box wide, can be new/old infarct

STEMI - J point STE >0.1 mV in any 2 contiguous leads, except

 • V2-V3: ≥0.25mV men <40; ≥0.2mV men ≥40; ≥0.15mV women

 • DDx: Acute STEMI, Aortic dissection, PE, peri/myocarditis (diffuse STE, diffuse PR dep)

NSTEMI/UA - 2 contiguous leads of 0.5mm downgoing ST or 1 mm T inversion with big R or R/S>I

STEMI Equivalents / Don't Miss Signs of Ischemia

 - hyperacute T waves - broad, prominent asymmetrical, similar or bigger than QRS

 - deWinter T waves - starts below isoelectric line; upsloping ST dep and peaked T in precordial leads with STE in avR

 - Wellen's T - biphasic/deep-symmetric inverted T V2-4 can have no pain - LAD stenosis

 - U wave inversion

 - STE avR - proximal LAD or high burden triple vessel disease

 - ST depression or T wave inversion in avL - early inferior MI

 - R/S >1 or ST depression in VI-V2 - posterior infarct, get a 15 lead

 - STE V1 >V2 or STE/isoeIectric in VI with depression in V2 - RV infarct

 - New tall T wave in V1 - normal T is inverted in V1, unless LBBB/LVH/high voltage



- Dr. Michael Wong @mchlwng



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