ACS-OMI
Results:
New RBBB and LAFB (Bifascicular Block) in ACS
Key Points Think proximal LAD / septal ischemia until proven otherwise when a patient with ischemic symptoms develops new RBBB + LAFB, especially with hemodynamic instability. Do not “normalize” ST…
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…
Prominent Upright T Wave in V1
Key Points: Normal T Wave in V1: The normal ECG typically shows a flat or inverted T wave in lead V1 in sinus rhythm. An upright T wave in V1 can…
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…
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…
Isoelectric Segment of the ECG
Key Points The reference for ST-segment shift is the J point relative to an isoelectric baseline. The two candidates for that baseline are the TP segment and the PR segment….
STEMI vs Artifact: DDx
Key Points: Not all ST elevation is ischemia. The most common mimics at the point of care are atrial activity riding on the ST segment, motion or lead artifact, early…
Ischemia & Infarction Interpretation
Key Points: The ECG is the fastest bedside tool for detecting acute coronary occlusion and dynamic ischemia, often before troponin changes and sometimes before classic symptoms. Acute coronary syndromes are…
Right Ventricular STEMI: Criteria & Pitfalls
Key Points RV involvement accompanies up to ~40% of inferior STEMIs; isolated RV infarction is uncommon but high-impact when missed. Think RV MI when inferior STEMI is present and you…
Terminal QRS Distortion: OMI Pattern
Key Points: What it is: In V2 or V3, there is no S wave (the R does not descend below the PQ baseline) and no J wave (no notch/slur at…
Pseudonormalization of T Waves
Key Points Definition: Pseudonormalization is the apparent normalization of previously inverted T waves, often signaling reocclusion of a coronary artery that had recently reperfused. Mechanism: During reperfusion, ischemic T wave…
Aslanger Pattern: OMI Pattern
Key Points: STEMI Diagnosis and Contiguous Leads: While current guidelines typically require ST elevation (STE) in at least two contiguous leads for the diagnosis of STEMI, this practice is not…
Precordial Swirl: OMI Pattern
Key Points Definition: The precordial swirl sign refers to a rotational pattern of ST-segment abnormalities across the precordial leads, suggesting a dynamic and evolving occlusion myocardial infarction (OMI). It is…
EMS ECGs in Acute Coronary Syndromes (ACS)
Key Points for EMS Providers: You are the first critical link in the chain of survival for ACS patients—your actions set the course for their care, directly impacting time to…
Subtle ST Segment Elevation: OMI Pattern
Key Points: ACS Dynamics: Occluded arteries in ACS can spontaneously reperfuse and reocclude, making ECG findings variable. Limitations of Computer Interpretation: Subtle STE is often missed by computerized ECG interpretation;…
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