ecg mimics of myocardial ischemia and infarction · imics of myocardial ischemia and infarction...

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  • 1IMICS OF MYOCARDIAL ISCHEMIA AND INFARCTION REVISED FOR LAS VEGAS 2008

    N G ld hl M D

    ECG MIMICS OF MYOCARDIAL ISCHEMIA AND INFARCTION

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    Nora Goldschlager, M.D.Cardiology – San Francisco General Hospital

    UCSF

    Disclosures: None

    PITFALLS IN THE ACCURACY OFTHE ECG DIAGNOSIS OF ACUTE MI

    • Nonspecific ST/T wave abnormalities• Age of Q-waves (may not be known)• Paced ventricular rhythm• Left bundle branch block• Right bundle branch block: secondary

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    • Right bundle branch block: secondary ST-T abnormalities in V1-3 can mimic anterior wall MI; tall R waves in V1-2 can mimic posterior wall MI

    • Nonspecific intraventricular conduction delay with repolarizationabnormalities

    DIAGNOSIS OF ACUTE MI IN LBBB• 1 mm ST segment change in same direction

    as terminal QRS• More than 5 mm ST elevation in direction

    opposite to QRS• Sgarbossa criteria (NEJM 1996;334:481)

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    - ST-elevation > 1 mm in lead withconcordant QRS complex 5 points

    - ST-depression > 1 mm in leadsV1, V2 or V3 3 points

    - ST-elevation > 5 mm in lead withdiscordant QRS complex 2 points

  • 2IMICS OF MYOCARDIAL ISCHEMIA AND INFARCTION REVISED FOR LAS VEGAS 2008

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    Same patient, baseline ECG obtained 6 months earlier

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  • 3IMICS OF MYOCARDIAL ISCHEMIA AND INFARCTION REVISED FOR LAS VEGAS 2008

    PITFALLS IN THE ECGDIAGNOSIS OF ACUTE MI: MI MIMICS - 1

    • Early repolarization• Electrolyte disorders

    HyperkalemiaHypokalemia

    • Inflammatory conditionsPericarditis

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    Pericarditis(PR depression, scooped ST segments, J point elevation)Myocarditis

    • Conduction system disordersFascicle blocks

    Anterior qV2-3, 1, aVLPoor R progression

    Posterior q II, III, aVF

    PITFALLS IN THE ECGDIAGNOSIS OF ACUTE MI: MI MIMICS - 2

    • Accessory pathways: - ventricular pre-excitation• Cardiac conditions

    LVH, RVHHCM

    • ArrhythmiasWid QRS t h di

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    Wide QRS tachycardiasEctopic atrial tachycardias with prominent

    Ta wavesPaced ventricular rhythm with inapparent

    pacing artifactsJunctional or ventricular tachycardias with

    retrograde conductionAtrial flutter with flutter waves pseudo ST or Brugada pattern

    PITFALLS IN THE ECG DIAGNOSISOF ACUTE MI: MI MIMICS - 3

    • Other

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    Osborne wavesPneumothorax with mediastinal shiftDouble standardization

  • 4IMICS OF MYOCARDIAL ISCHEMIA AND INFARCTION REVISED FOR LAS VEGAS 2008

    EARLY REPOLARIZATION

    • Prevalence about 1%• Male prevalence (87% in men, 33% in women)• Age less than 50 (OR 3.3)

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    g ( )• High prevalence in black and Asian races• High prevalence in athletes• Benign clinical course• Exercise and hyperventilation normalize the

    pattern

    EARLY REPOLARIZATION: ECG FEATURES

    • J point elevation• Terminal R wave notch• Upwardly concave ST segments• PR segment depression often seen

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    g p• PR interval often short• Bradycardia common• Best seen in precordial leads (usually

    V2-4); unusual in limb leads• Early transition common• T waves tall and asymmetric• U waves often present (may be negative)

    HYPERKALEMIA vs ANTERIOR OR INFEROPOSTERIOR WALL MI

    vs BRUGADA PATTERN

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  • 5IMICS OF MYOCARDIAL ISCHEMIA AND INFARCTION REVISED FOR LAS VEGAS 2008

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  • 6IMICS OF MYOCARDIAL ISCHEMIA AND INFARCTION REVISED FOR LAS VEGAS 2008

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  • 7IMICS OF MYOCARDIAL ISCHEMIA AND INFARCTION REVISED FOR LAS VEGAS 2008

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  • 8IMICS OF MYOCARDIAL ISCHEMIA AND INFARCTION REVISED FOR LAS VEGAS 2008

    Isoelectric mimicking pauses

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    PR ST scoop

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  • 9IMICS OF MYOCARDIAL ISCHEMIA AND INFARCTION REVISED FOR LAS VEGAS 2008

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  • 10IMICS OF MYOCARDIAL ISCHEMIA AND INFARCTION REVISED FOR LAS VEGAS 2008

    RETROGRADE P WAVES –PSEUDO ST DEPRESSION

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    Flutter - Pseudo ST elevation

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  • 11IMICS OF MYOCARDIAL ISCHEMIA AND INFARCTION REVISED FOR LAS VEGAS 2008

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  • 12IMICS OF MYOCARDIAL ISCHEMIA AND INFARCTION REVISED FOR LAS VEGAS 2008

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    37 y.o. O “found down”

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    6 hrs. later: T° 25° 30° C

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  • 13IMICS OF MYOCARDIAL ISCHEMIA AND INFARCTION REVISED FOR LAS VEGAS 2008

    J (OSBORNE) WAVE

    Results from electrical heterogeneitybetween ventricular endo- and epicardiumduring repolarization

    Seen in:

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    • Hypothermia• Hypercalcemia• Intracranial (subarachnoid) bleed• Brugada syndrome• Coronary vasospasm• Idiopathic VF• ? ischemia

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  • 14IMICS OF MYOCARDIAL ISCHEMIA AND INFARCTION REVISED FOR LAS VEGAS 2008

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  • 15IMICS OF MYOCARDIAL ISCHEMIA AND INFARCTION REVISED FOR LAS VEGAS 2008

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