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STEMI Equivalents…an opportunity to save myocardium
Susan P. Torrey, MD, FAAEM, FACEPAssociate Professor of Emergency Medicine
Tufts University School of Medicine
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Disclosures
•None•Nada•Niente
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We all know what to do with this…
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STEMI Equivalents
• Critical left main disease• Isolated posterior MI• Wellens’ syndrome• Persistent hyperacute T waves (de Winters)
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Case 1. 70-yo farmer with chest pain
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Critical Left Main Artery Disease
• Wellens described association with:• ST-segment depression ≥ 8 leads• ST-segment elevation in lead aVR
• Especially if ST-elevation in aVL
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Another critical left main stenosis
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A recent case - EMS EKG
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EKG in the ED
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90% left main occlusion
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Case 2. 48-yo man with chest pain
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Isolated posterior wall MI
• Posterior MI usually with inferior MI• 5% MIs - isolated posterior wall
• Isolated posterior wall MI• ST-segment depression V1-3
• As MI evolves:• Upright T waves V1-3• Tall R waves V1-2
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Acute inferior – posterior MI
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ST-segment depression in V1-3
ST-depression in V1-3
With flipped EKG ST elevation“inverted reflection”
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A recent case – circ stent
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Evolving posterior MI with tall R-V2
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Case 3. 65-yo woman with 90 mins severe substernal
chest pain earlier
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Wellens’ warning• Left anterior descending (LAD)• Associated with changes V2-4
• Deeply inverted T waves• Biphasic T waves
• Change from initial normal EKG• During pain-free interval• Normal enzymes
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Wellens’ syndrome
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Wellens’ syndrome, type 2
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Wellens’ original description - 1982
• 18% of admitted unstable angina
• If NOT revascularized 75% large anterior MI…within weeks
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60-year-old man with chest pain
earlier in the day
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ECG from 1 month prior
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Previous EKG Presentation
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One week later…
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4. 60-year-old man with chest pain
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de Winter’s sign
• Persistent hyperacute T’s• ST-segment depression
• Proximal LAD occlusion• 2% of anterior MIs
de Winter NEJM 2008
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In conclusion…
Remember these STEMI equivalents
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In conclusion…
• Critical left main occlusion
ST-depression ≥ 8 leadsST-elevation aVR
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In conclusion…
• Critical left main occlusion• Isolated posterior MI
ST-depression in V2-3
Evolving tall R in V1-2
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In conclusion…
• Critical left main occlusion• Isolated posterior MI• Wellens’ warning
Inverted or biphasic T waves V2-3
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In conclusion…
• Critical left main occlusion• Isolated posterior MI• Wellens’ warning• de Winter’s sign
Persistent hyperacute T wavesST depression
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ESC STEMI GuidelinesEurop H J 33:2569, 2012
•Specifically address:• Isolated posterior infarction• Left main coronary obstruction
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Cardiol Clin 30:591-599, 2012