https://wikem.org/w/api.php?action=feedcontributions&feedformat=atom&user=ShanyarMDWikEM - User contributions [en]2026-05-13T21:38:11ZUser contributionsMediaWiki 1.38.2https://wikem.org/w/index.php?title=STEMI_equivalents&diff=49298STEMI equivalents2015-12-03T22:13:43Z<p>ShanyarMD: The two types of Wellen's syndrome were reversed. According to Tintinalli's EM & lifeinthefastlane this is the correct classification.</p>
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<div>==Background==<br />
*Standard teaching for STEMI typically has the following criteria<ref>ECC Committee, Subcommittees and Task Forces of the American Heart Association.. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care — Part 8: Stabilization of the Patient With Acute Coronary Syndromes. Circulation. 2005. 112 (24_suppl):IV–89–IV–110. 2005.</ref><br />
**≥1 mm (0.1 mV) of ST segment elevation in the limb leads<br />
**≥ 2 mm elevation in the precordial leads and present in anatomically contiguous leads<br />
*There are several variations from the classic STEMI ECG changes that do not fit this definition<br />
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==STEMI Equivalents==<br />
===Posterior MI===<br />
*RCA (90%), LCA (10%)<br />
*12-Lead ECG findings<ref>Van Gorselen EO, et al. Posterior myocardial infarction: the dark side of the moon. Neth Heart J. 2007; 15:16-21.</ref><br />
**ST-segment depression (horizontal >> downsloping/upsloping<br />
**Prominent and broad R wave (>30ms)<br />
**R/S wave ratio >1.0 in lead V2<br />
**Prominent, upright T wave<br />
**Combination of horizontal ST-segment depression with upright T wave<br />
*Posterior ECG or 15-lead ECG may be helpful<br />
**V7: Left posterior axillary line along the 5th ICS<br />
**V8: Tip of the left scapula line along the 5th ICS<br />
**V9: Left paraspinal area line along the 5th ICS<br />
*Posterior ECG findings<br />
**≥1 mm ST-segment elevation<br />
[[File:Posterior MI.jpg|350px]]<br />
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===LMCA Occlusion===<br />
*Seen with occlusion or near-occlusion of the left main artery<ref>Hennings JR and Fesmire FM. A new electrocardiographic criteria for emergent reperfusion therapy. Am J Emerg Med. 2012; 30(6):994–1000.</ref><br />
*Has been reported in occlusion of the proximal left anterior descending artery and severe multivessel coronary artery disease<br />
*12-Lead ECG findings<br />
**ST elevation in aVR ≥ 1mm<br />
**ST elevation in aVR ≥ V1<br />
**ST depression typically seen in lateral <br />
[[File:AVR.jpg|350px]]<br />
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===[[De Winter’s T Waves]]===<br />
*Suggestive of proximal LAD lesion<br />
*12-Lead ECG findings<ref>de Winter R, et al. A new ECG sign of proximal LAD occlusion. NEJM. 2008; 359:2071–2073.</ref><br />
**Precordial ST-segment depression at the J-point<br />
**Tall, peaked, symmetric T waves in the precordial leads<br />
**Lead aVR shows slight ST-segment elevation in most cases<br />
[[File:Dewinter.jpg|350px]]<br />
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===[[Sgarbossa's Criteria]]===<br />
*Used to identify STEMI in the setting of LBBB or pacemaker<br />
*Original Criteria<ref>Sgarbossa E, et al.. "Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block. GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) Investigators". NEJM. 1996; 334(8):481-7.</ref><br />
**≥3 points = 98% probability of STEMI<br />
**ST elevation ≥1 mm in a lead with upward (concordant) QRS complex - 5 points<br />
**ST depression ≥1 mm in lead V1, V2, or V3 - 3 points<br />
**ST elevation ≥5 mm in a lead with downward (discordant) QRS complex - 2 points<br />
*Smith's modification<ref>Smith, S, et al. Diagnosis of ST-Elevation Myocardial Infarction in the Presence of Left Bundle Branch Block With the ST-Elevation to S-Wave Ratio in a Modified Sgarbossa Rule. 60(6):766-776.</ref><br />
**Changes the 3rd rule of original Sgarbossa's Criteria to be ST depression OR elevation discordant w/ the QRS complex and w/ a magnitude of at least 25% of the QRS increases Sn from 52% to 91% at the expense of reducing Sp from 98% to 90%[<br />
[[File:Sgarbossa.jpg|350px]]<br />
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===[[Wellens’ Syndrome]]===<br />
*ECG findings in absence of chest pain, but with recent cardiac chest pain symptoms<br />
*Represents critical stenosis of the LAD<br />
*Not necessarily STEMI equivalent but will require PCI in the next 24-48hr<br />
*12-Lead ECG findings<ref>Rhinehardt J, et al. Electrocardiographic manifestations of Wellens' syndrome. Am J Emerg Med. 2002; 20(7):638-43.</ref><br />
**Deeply-inverted or biphasic T waves in V2-3<br />
**Isoelectric or minimally-elevated ST segment (<1 mm)<br />
**Absent precordial Q waves with preserved R waves<br />
*Two T wave characteristics:<br />
**Type A: Biphasic pattern - 25% - Biphasic T-waves (initial + deflection and terminal - deflection)<br />
**Type B: Inversion pattern - 75% - Deeply inverted and symmetric T-waves<br />
[[File:Wellens.jpg|350px]]<br />
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==No Longer STEMI Equivalents==<br />
===[[LBBB|New LBBB]]===<br />
*New LBBB alone is no longer a reason to activate the cath lab<ref>Jain S, et al. Utility of left bundle branch block as a diagnostic criterion for acute myocardial infarction. Am J Cardiol. 2011; 107:1111-1116.</ref><br />
*However, careful w/u for ACS should be taken for symptomatic patients with LBBB<br />
*12-Lead ECG findings<br />
**QRS > 0.12 in limb leads<br />
**Leads<br />
***Large and wide R waves — leads I, aVL, V5, and V6<br />
***Small R wave followed by deep S wave —leads II, III, aVF, V1–V3<br />
[[File:LBBB.jpg|350px]]<br />
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==See Also==<br />
*[[ST-Elevation Myocardial Infarction (STEMI)]]<br />
*[[Acute Coronary Syndrome (Main)]]<br />
*[[Chest pain]]<br />
*[[ECG (Main)]]<br />
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==External Links==<br />
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==References==<br />
<references/><br />
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[[Category:Cards]]</div>ShanyarMD