acute coronary syndromes disclosures · nstemi stemi ~90% 100% constant pain nstemi vs stemi...

Jon Tardiff, BS, PA-C�OHSU Clinical Assistant Professor�

Acute Coronary Syndromes� Disclosures�

• I work for Virginia Garcia� Memorial Health Center,� Beaverton, OR.�

• And I am a medical editor for Jones & Bartlett Publishing.�

Arabic, Somali, Mai Mai, Pashtu, Urdu, ASL, and more!�4�

Goals of this session�

• Identify Acute Coronary Syndromes �

(STEMI vs NSTEMI)�

• Identify old myocardial infarction�

• Distinguish between Right and Left BBB�

What a 12-Lead ECG can help you do�

•  Diagnose ACS / AMI�•  Interpret arrhythmias�•  Identify life-threatening syndromes (WPW,

LGL, Long QT synd., Wellens synd., etc)�•  Infer electrolyte imbalances�•  Infer hypertrophy of any chamber�•  Infer COPD, pericarditis, drug effects, and

more!�6�6666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666

For example:�73 y.o. male with nausea, syncope�

7�777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777

Acute Inferior MI�

ST elevation�

8�88888888888888888888888888888888

What rhythm? (look at V1 for P waves)�

9�9999999999999999999999999999999

P waves� Limitations of a 12-Lead ECG�

•  Truly useful only ~40% of the time�•  Each ECG is only a 10 sec. snapshot�•  Serial ECGs are necessary, especially for ACS�•  Other labs help corroborate ECG findings

(cardiac markers, Cx X-ray)�•  Confounders must be ruled out (LBBB, LVH,

WPW, digoxin, RVH, pericarditis, dissecting aneurysm)�

11�1111111111111111111111111111111111111111111111

Confounder: Left Bundle Branch Block�

12�1212121111112121212121111121112112212111211112111111111111111121111121111111

Impending AMI with normal ECG!�

13�1313131313131313131331313111311313111111131313131313131111113131313333333333333333333333333333313

13 hrs later — Acute Anterior MI�

Elevated ST segments�

14�

ECG Lead Placement�&�

Electrophysiology Review�

15�

�  I �  II �  III

Limb Leads�

(standard leads)

-� ±�

+� 16�

Rapid Interpretation Tips�

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RRaapid Interpreettatttttiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiioooooooooooooooooooooooooooooooooooooooooooooooonnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn TTTiipss

Dr. Willem Einthoven�

17�

Leads I, II, III�

I

II III

Normal 12-Lead ECG�

SA Node AV Node His Bundle BBs Purkinje Fibers�

P�

Q�

R�

S�

T�

II�

U�

Conduction System�

20�Q�

R�

S�

P wave axis�

R wave axis�

…upright in L II�

…upright in L II�

Lead II�

21�21�

PR�

II�

Intervals�

PR Interval: 120 – 200 mSec (3 – 5 boxes) �QRS width: 60 – 120 mSec (1 ½ – 3 boxes) �QT/QTc interval: 400 mSec (10 boxes)�

QT�QRS�

22�

�  I �  II �  III �  aVR �  aVL �  aVF

Limb (frontal plane) Leads�

(augmented leads)

(standard leads)

23�

Augmented Leads�

aVR

aVL

aVF


25�

6 Frontal Plane Leads (limb leads)�

I

II III

R

L

F

Axis�

26�

Leads � I� II� III� aVR*� aVL� aVF�

-�

27�

QRS Morphology in Lead II�

II�

Axis Determination�

29�

Why We Care About Axis Deviations�

The axis shifts towards hypertrophy�& away from infarction�

The axis also shifts for ectopic rhythms, such as V-Tach�

Normal axis is -20° to +110°�

30�

Axis Deviation�

Horizontal heart (0°): obesity, � 3rd trimester pregnancy. Ascites�

Vertical heart (90°): slender build�

Left Axis Deviation: LBBB,� Anterior MI, Inferior MI, Left� anterior hemiblock, LVH�

Right Axis Deviation: Anterior MI,� Lateral MI, RBBB, COPD, RVH,� Left posterior hemiblock�

Extreme RAD: Ectopic rhythm� (VT), MI�

31�

How to determine Axis�

Easiest: the computer does it for you!�

Pretty Easy: Thumbs up / Thumbs down�

A Little Harder: find the tallest R wave � (if tallest is Lead II = normal axis)�

32�

Practice: Axis� 1�

I�

F�

33�

Axis Practice� 1�

333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333

Normal Axis�

I�

F�

1�

34�

2�

I�

F�

35�

2�Left Axis Deviation�

I�

F�36�

3�

37�

3�

37373737377777737373777377777777777777777737777373777377737373377737773333333333377773333333333733333377777333373737333333333333373333

Right Axis Deviation�

38�

4�

39�393933939939333333933333333939993933339999393993333393333333333333333933333333

4�

Extreme Right Axis Deviation�

40�

�  I �  II �  III �  aVR �  aVL �  aVF

�  V1 �  V2 �  V3 �  V4 �  V5 �  V6

Limb (frontal plane) Leads�

(augmented leads)

(standard leads) (anterior

leads)

(lateral leads)

Chest (precordial) Leads�

41�

V Lead Cutaway�

V Lead Progression�


45�45 46�

Step-by-step method for reading a 12-Lead�


Rapid Interpretation Tips�•  Identify the rhythm. If supraventricular*, �

If no LBBB,�

�If present, �

•  Rule out other confounders: WPW, pericarditis, LVH, digoxin effect�

•  Identify location of infarct, and consider appropriate treatments: MONA, PCI [or fibrinolytic], nitrate infusion, heparin infusion, GP IIb, IIIa inhibitor, beta-blocker, clopidogrel, statin, etc. �

Supraventricular rhythms�

•  Sinus rhythm�

•  Atrial fibrillation�

•  Junctional rhythm�

•  PSVT�

•  Atrial tachycardia�

•  Atrial flutter�

•  Wandering atrial pacemaker�

•  Multifocal Atrial Tachycardia�

Normal 12-Lead ECG�Rapid Interpretation Tips�

Rapid Interpretation Tips�•  Identify the rhythm. If supraventricular, �

If no LBBB,�

�If present, �



The Problem with Bundle Branch Blocks�

•  Dyssynchronized contraction of the ventricles�•  Reduced cardiac output�•  Worsened heart failure�•  LBBB confounds the EKG interpretation� —LBBB makes it harder to find ACS�

52�

Bundle Branch Blocks (QRS > 0.12 sec.)

Left BBB (L I, V5, V6: upright QRS with a notch)

Right BBB (V1, V2, MCL1: rsR’ pattern)

R’

S

r

notch I V1

(left-sided lead) (right-sided lead)

53�

Bundle Branch Blocks Two QRSs

5353553535353535535355555553535553353553553535553335

notch I

Healthy ventricle�

Blocked bundle�

R’

S

r V1 slur I

V1 & V2�

RBBB�

V5 V6�

(& I, aVL)�

LBBB�

56�

Practice: Bundle Branch Block�

RBBB�

Which Bundle Branch is Blocked?� 5�

RBBB�

Right Bundle Branch Block (Lead V1)� 5�

LBBB 12-Lead�

Which Bundle Branch is Blocked?� 6�LBBB 12-Lead�Left Bundle Branch Block�

(L I, V5, V6)�

6�

Where is the Pathology?� Right Bundle Branch Block�

63�

64�

Left Bundle Branch Block�

65�

New 12-Lead ECG Format�

aVL�

I�

-aVR�

II�

aVF�

III�

New 12-Lead ECG Format�

aVL�

I�

-aVR�

II�

aVF�

III�

New �

Old�


Rapid Interpretation Tips�•  Identify the rhythm. If supraventricular, �

•  Rule out left bundle branch block. If no LBBB,�

•  Check for: ST elevation, or ST depression with T wave inversion, and/or pathologic Q waves. �

�If present, �



Ischemia� Injury� Infarction�Normal�

STEMI�

ST elevation, ST depression, T wave inversion, pathologic Q waves�

NSTEMI?�

Percutaneous Coronary Intervention�

71�

RCA before and after stenting�

Before stenting� After stenting�

The Spectrum of Acute Coronary Syndromes�

Healthy� CAD� Angina� Unstable Angina� NSTEMI� STEMI� Shock /� Death�

Patent�artery�

~50%� ~70%� >70%� or 100%� ~90%� 100%� 100%�(or vasospasm)�

No symptoms� Pain on� exertion�

Pain at rest;�relieved by NTG� Constant pain�

NSTEMI� STEMI�

~90%�100%�

Constant pain�

NSTEMI vs STEMI�

Constant pain�

STEMI: ECG Changes�A. Normal ECG�B. Hyperacute T wave changes - increased T wave amplitude and width; may also see ST elevation�C. Marked ST elevation with hyperacute T wave changes (transmural injury)�D. Pathologic Q waves, less ST elevation, terminal T wave inversion (necrosis)�E. Pathologic Q waves, T wave inversion (necrosis and fibrosis) �F. Pathologic Q waves, loss of R waves (fibrosis)�

(w/onset cx pn)�

(20 minutes)� (1 hour)�

(1 week – years)�(>1 hr)�

(normal)�

75�

Why Pathologic Q Waves Form�

Normal q� Pathologic Q�

MI ECG Patterns�MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEECCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaattttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttteeeeeeeeeeeeeeeeeeeeeeeeeeeeerrrrrrrrrrrnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnssssssssssssssssssssssssssssssssssssssssssssssssssssssss

NSTEMI�(non Q wave MI)�

77�

STEMI — Typical Progression� Acute Inferior MI#1�


ST elevation�

Qs� Qs�

Axis is shifting leftward…�

Acute Inferior MI #2�

Same Patient~2 hrs later�

Worsened ST elevation�

Qs� Qs�

New ST elevation�

Acute Inferior MI #3�Same Patient 9 days later�

Permanent Q waves�(inferior wall scar)�

But NO anterior infarct (no Qs)�

Permanent left axis deviation�

Acute Anterior MI Page�AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAccccccccccccccccccccccccccccccccccccccccccccccuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuutttteeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnttttttttttttttttttttttttttttttttteeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeerrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrriiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiioooooooooooooooooooooorrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaggggggggggggggggggggggggggggggggggggggggggggggggggggggeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee

45% of MIs�

Acute Inferior MI Page�AAAAAAAAAAAAAAAAAAAAAAAAAAAAcccccccccccccuuuuuuuuuuuuuuteeeeeeeeeeeeeeeee IIIIIIIIIIIIIIIIIIInnnnnnnnnnnnnnnnnnfffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffeeeeeeeeeeeeeerrrrrrrrrrrrrrrrrriiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiooorrrrrrrrrrrrrrrrrrrrrr MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMIIIIIIIIIIIIIIIIIIIIIII PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPaaaaaaaaaaggggggggggggggggggggggggggggeee

40% of MIs�

Acute R Ventricle MI Page�AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAcccccccccccccccccccccccccccuuuuuuuuuutttttttttttttttttttttttttteeeeeee RRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRR VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVeeeeeeeeeeeeeeennnnnnnnnntrrrrrrriiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiccccccccccccccccccccccccccccccclllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllleeeeeeee MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMIIIIIIIIIIIIIIIIIIIIIIIIIIII PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggeeeeeeeeeeeeeeee

1/3 of Inferior MIs�

Acute Lateral MI Page�AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAcutttttttttttttttttttttttttttte LLLLLLLLLLLLLLLLLLLLLLLLLLLLatttttttttttttterallllllllllllllllllllllllllllllllllll MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMI PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPaggggggggggggggggggggggggggggggggggggggggggeeeeeeeeeeeeeeeee

15% of MIs�

Acute Posterior MI Page�AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAcccccuuuuuuutttttttttttttttttttteeeeeee PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPooooooossssssssssttttttttttttttteeeeeerrrrrrrrrrrrrriiiiiiiiiiiiiiiiiiiiooooooooooooooooorrrrrrrrrr MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMIIIIIIIIIIIIIIIII PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPaaaaaaaaaaaaggggggggggggggggggggggeeeeee

86�

Practice: Infarct Location�

Acute Anterior MI�

Where is the Pathology?� 7� Acute Anterior MI�(ST Elevation in V1 - V4)�

ST Elevation�

What is the R wave axis?�

7�


Where is the Pathology?� 8�Acute Inferior MI�

Acute Inferior MI�(ST elevation in II, III, F)�

8�

Acute Inferolateral MI�

Where is the Pathology?� 9�Acute Inferolateral MI�Acute Inferolateral MI �

(ST elevation in II, III, F, V5, V6)�

Note the axis has not shifted and there are no loss of R waves yet, because it is early in the AMI,. �

9�

Where is the Pathology?� 10� Acute Inferior MI & Right Ventricle MI�10�

Where is the MI?�

Normal V1 – V3�

• V1, V2, V3�• Large R Waves�• Depressed STs�

ST Depression�

Large R waves�

11� Acute Posterior MI�

Normal V1 – V3�

• V1, V2, V3�• Large R Waves�• Depressed STs�

ST Depression�

Large R waves�

11�

Where is the Pathology?�

LAE�

LBBB�

LBBB�

Left Bundle Branch Block�

Anterior MI�

MI? What rhythm is this?�

Anterior MI�

Sinus Tach� Acute Anteroseptal MI�

Elevated ST segments�

Rhythm? Pathology?�Acute Inferolateral MI�

Elevated STs II, III, aVF, V5, V6�

MI? Rhythm?�AF? Acute Anterolateral MI�

Hyperacute T waves V3–V6�(early sign of AMI)�

Elevated STs�

Case report:�

58 y.o. male c/o chest “tightness” and shortness of breath x 20 minutes, which gradually subsided. Recurrent episodes over several months. Pt thought it was “acid reflux”, but finally goes to ED. Pt is noncompliant with statin therapy, & admits to poor diet. Family Hx cardiac disease. Hx HTN. Meds: Plavix, ACE inhibitor. �

EKG follows. What treatment?�Angiography reveals 90% occlusion in some coronary arteries. �

HIPPA note: �this is NOT�Bill Clinton’s�actual ECG!�

12�

Treatment: quadruple CABG (coronary artery bypass graft).�

Ischemia / Impending MI�

no loss of R waves yet…�

…but inverted T waves�

But he did have a CABG & became adherent to his meds!�

12� Excellent outcome:�Pt is active, healthy, has improved diet, is compliant with meds; and has inspired thousands of Americans to go to their providers for cardiac evaluations… �

“The Bill Clinton Effect”�

109�01010101011101010101010101111111110111111011010100010101000100010000999999999999999999999999999999999999999

Rhythm? Pathology?� 13�

110�1111111111111111111111111111111111111111111111111111111111111111111111110000000000000000000000000000000000000

Large Old Anterolateral MI�

Large Qs V1–V6�

Ventricular aneurysm�

Ventricular aneurysm�

13�

I also teach…�

• Arrhythmia interpretation� (SVTs, heart blocks, etc.)�

• Just Say “NO” to Drug Seekers�

• and an EKG game:� “The Rhythm Method™”�

“The Rhythm Method™”�

[email protected]�

acute coronary syndromes disclosures · nstemi stemi ~90% 100% constant pain nstemi vs stemi...

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