ACS-OMI
Results:
Earliest Evidence of Occlusion MI
Key Points ACS is dynamic. Coronary arteries can occlude, partially reperfuse, and re-occlude over minutes to hours, and the ECG can show these shifts before biomarkers do. The earliest actionable…
Post-Thrombolytic Reperfusion ECG Findings
Key Points Reperfusion after fibrinolysis is a bedside diagnosis using a bundle of findings: symptoms, ECG trend, and hemodynamic/electrical stability. Best ECG marker of successful fibrinolysis: at least 50% ST-segment…
ECG Evidence of Reperfusion After Occlusion
Key Points Reperfusion and re-occlusion can occur spontaneously or after therapy. The ECG often reflects these changes earlier than symptoms. Most useful bedside ECG marker of reperfusion is ST-segment resolution…
Early Reciprocal Changes: OMI Pattern
Key Points STEMI criteria alone miss some acute coronary occlusions, so look for subtle “occlusion clues,” not just traditional STEMI criteria cutoffs. Minor ST elevation under 1 mm paired with…
STEMI & Equivalent Patterns: Criteria & Pitfalls
Key Points STAT ECG: The most important initial test in evaluating acute coronary syndromes (ACS). The primary goal is to quickly identify patients with STEMI or STEMI-equivalent patterns that trigger…
Acute Coronary Syndromes (ACS)
Key Points ACS is a clinical syndrome: classified by ischemic symptoms + ECG + troponin. ACS exists on a continuum of unstable angina, NSTEMI, STEMI, and patients can evolve between…
ST Depression in V1-V4: DDx
Key Points: Do not reflexively label ST depression in V1–V4 as “anterior ischemia/NSTEMI.” In ACS symptoms, posterior OMI is a major concern when the depression is most prominent in V1–V3…
ST Elevation: DDx
Key Points Definition: ST elevation refers to upward displacement of the ST segment above baseline, often signaling acute myocardial injury. Clinical Importance: While most concerning for STEMI due to acute…
de Winter T Waves: STEMI Equivalent Pattern
Key Points STEMI Equivalent: The de Winter ECG pattern is an uncommon STEMI equivalent indicative of an unstable proximal occlusion of the LAD (left anterior descending coronary artery). Treat the…
Pseudo-Wellens Waves
Key Points Pseudo-Wellens waves are anterior T-wave patterns that mimic the biphasic or deeply inverted T waves of true Wellens syndrome but are caused by non-LAD, non-ischemic physiology. These normal-variant…
Wellens Syndrome
Key Points Clinical diagnosis, not an ECG pattern alone. Wellens syndrome requires the characteristic ECG findings plus the appropriate clinical scenario. Morphology alone is insufficient and high-risk if misapplied. Critical…
Wellens Waves
Key Points Wellens waves are anterior precordial T wave abnormalities (biphasic or deeply inverted) most often in V2–V3, occasionally extending to V1 and V4–V6. They signal a high likelihood of…
Shark Fin “Massive STEMI” Pattern
Key Points: High-risk STEMI morphology caused by fusion of the terminal QRS, J point, ST segment, and T wave into a single “triangular” deflection. Often massive apparent STE with loss…
Spontaneous Coronary Artery Dissection (SCAD)
Key Points SCAD Definition: A spontaneous, non-atherosclerotic tear in the coronary artery wall, often affecting young, otherwise low-risk women (including peripartum patients). SCAD presents similarly to ACS and is an…
STEMI Mimics: DDx
Key Points Context Matters: ECGs must be interpreted in the clinical setting. Chest pain, shock, or ACS risk factors increase pretest probability of STEMI/OMI, while atypical presentations lower it. Prevalence:…
Tall R wave in V1: DDx
Key Points Normal expectation: In V1, the S wave is typically larger than the R wave. A tall or dominant R wave (R/S > 1) is abnormal and should prompt…
Tall R wave in aVR: DDx
Key Points Normal expectation: In aVR, the QRS is usually negative (deep S wave). A dominant or tall R wave (R > S) is abnormal and should prompt investigation. Mechanism:…
Hyperacute T Waves: OMI Pattern
Key Points: Complexity of ACS: Arteries can spontaneously reperfuse or re-occlude. Understanding early ECG patterns of early acute ischemia can help detect dynamic changes and prompt rapid interventions. ECG Pattern…
ST Elevation in aVR: DDx
Key Points Global Subendocardial Ischemia: ST elevation (STE) in aVR with diffuse ST depression elsewhere usually reflects global subendocardial ischemia. Proximal Occlusion or Severe CAD: Common in left main (LMCA)…
Takotsubo Cardiomyopathy vs STEMI: DDx
Key Points Takotsubo (stress) cardiomyopathy is a transient, non-ischemic LV dysfunction—classically apical ballooning with basal hyperkinesis—often after emotional or physical stress. Presentation mimics occlusion MI (chest pain, ECG changes, elevated…
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