1/ Today's 🧵is about "STEMI Equivalents".
The aim of this thread is to provide a basic guidance on recognizing EKG patterns in cases with coronary artery occlusion where the ST-segment elevation is not present in contiguous leads.
Based on the expert consensus published by the American College of Cardiology in 2022.
@ekgdx #ekgdx #CardioTwitter
The aim of this thread is to provide a basic guidance on recognizing EKG patterns in cases with coronary artery occlusion where the ST-segment elevation is not present in contiguous leads.
Based on the expert consensus published by the American College of Cardiology in 2022.
@ekgdx #ekgdx #CardioTwitter
2/ For the last twenty years, studies have demonstrated that acute coronary occlusion (ACO) does not always produce the classic ST-segment elevation in contiguous leads (Koyama et al Am J Cardiol 2002). In fact, the following study has suggested that >25% of patients with ACO will not demonstrate expected ST-segment elevation (Wang, T. @CMichaelGibson et al Am Heart J 2009).
Link: sciencedirect.com
@ekgdx #ekgdx
Link: sciencedirect.com
@ekgdx #ekgdx
3/ In 2022, the American College of Cardiology published the expert consensus decision pathway on the evaluation and disposition of acute chest pain in the emergency department.
Most notably for our debate, the panel highlighted causes of non-ST elevation acute coronary occlusion, or what they refer to as "STEMI Equivalents.
Link: jacc.org
@ekgdx #ekgdx
Most notably for our debate, the panel highlighted causes of non-ST elevation acute coronary occlusion, or what they refer to as "STEMI Equivalents.
Link: jacc.org
@ekgdx #ekgdx
4/ It's time to start with the STEMI Equivalents.
The first one is the Posterior acute MI.
Controversy exists regarding the existence of posterior myocardial infarction. It has been suggested that the electrocardiographic findings described in this entity correspond to infarction of the lateral wall (due to the oblique arrangement of the heart) and in the segmentation model, the posterior wall is replaced by the basal inferior segment.
Bayes de Luna 2007: revespcardiol.org
Manuel D Cerqueira et al 2002: ahajournals.org
@adribaran @ekgdx #ekgdx
The first one is the Posterior acute MI.
Controversy exists regarding the existence of posterior myocardial infarction. It has been suggested that the electrocardiographic findings described in this entity correspond to infarction of the lateral wall (due to the oblique arrangement of the heart) and in the segmentation model, the posterior wall is replaced by the basal inferior segment.
Bayes de Luna 2007: revespcardiol.org
Manuel D Cerqueira et al 2002: ahajournals.org
@adribaran @ekgdx #ekgdx
6/ Hyperacute T waves
The panel also advised vigilance for the presence of hyperacute T waves, as these can be seen early in the presence of an acute coronary occlusion. However, they refrained from recommending immediate reperfusion therapy for these patients. Instead, they suggested conducting serial EKGs to monitor for any progression to ST-segment elevation myocardial infarction (STEMI).
@ekgdx #ekgdx
The panel also advised vigilance for the presence of hyperacute T waves, as these can be seen early in the presence of an acute coronary occlusion. However, they refrained from recommending immediate reperfusion therapy for these patients. Instead, they suggested conducting serial EKGs to monitor for any progression to ST-segment elevation myocardial infarction (STEMI).
@ekgdx #ekgdx
7/ Here is a good example of hyperacute T wave captured during a serial EKG in the setting of acute myocardial infarction due to total occlusion of the LAD.
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8/ In the consensus, they specifically indicated for the first time that patients with left bundle branch block (LBBB) patterns or right ventricular pacemakers who manifest Sgarbossa criteria or modified Sgarbossa criteria, and patients with de Winter pattern, should undergo emergent coronary angiography.
About Sgarbossa criteria, check this out.
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About Sgarbossa criteria, check this out.
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9/ About de Winter pattern, check this out
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12/ Here is an example of ST-segment elevation in aVR with diffuse ST-segment depression in the setting of AFIB. The angiogram showed multivessel disease and the patient was referred for CABG. Courtesy of @smithECGBlog.
13/ Wellens Syndrome
Gerson et al 1979: pubmed.ncbi.nlm.nih.gov
De Zwaan, Wellens et al 1982: pubmed.ncbi.nlm.nih.gov
@ekgdx #ekgdx
Gerson et al 1979: pubmed.ncbi.nlm.nih.gov
De Zwaan, Wellens et al 1982: pubmed.ncbi.nlm.nih.gov
@ekgdx #ekgdx
pubmed.ncbi.nlm.nih.gov/6121481/
Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction - PubMed
In patients admitted to the hospital because of unstable angina, a subgroup can be recognized that i...
pubmed.ncbi.nlm.nih.gov/487534/
Exercise-induced U-wave inversion as a marker of stenosis of the left anterior descending coronary artery - PubMed
The prevalence and cineangiographic correlates of exercise-induced inversion of U waves were studied...
17/ This consensus also marks a significant advancement in formally recognizing that many cases of acute coronary occlusion (ACO) do not exhibit typical ST-segment elevation in contiguous leads. I am optimistic that in the upcoming years, the national guidelines will start to acknowledge other equivalents of ST-segment elevation myocardial infarction (STEMI) as well.
#ekgdx
#ekgdx
18/ END
Thanks for reading this 🧵.
If you find this content helpful:
1- Follow @doctor_roig and @ekgdx for more.
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4- Read all my #Tweetorials of EKG down below.
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Thanks for reading this 🧵.
If you find this content helpful:
1- Follow @doctor_roig and @ekgdx for more.
2- Re-post the first tweet.
3- Activate my bell and don't miss my next thread.
4- Read all my #Tweetorials of EKG down below.
x.com
More than 107,000 views in less than 24 hours 😳.
Link: ekgdx.com
Link: ekgdx.com
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