A 62-year-old man presented with chest pain and sweating. His vital signs showed a heart rate of 110 beats/minute, respiratory rate of 30 breaths/minute, and blood pressure of 120/60 mmHg. An electrocardiogram (ECG) revealed ST segment elevations in the inferior and lateral walls consistent with an inferior and lateral wall ST-segment elevation myocardial infarction (STEMI). The document discusses the classification, diagnosis, and localization of ST segment changes seen in STEMI and non-ST elevation myocardial infarction (NSTEMI) on ECG. It also reviews pathological T wave changes and their potential causes.

1. ECG & ACS
Dr. Ajith Venugopalan.
MBBS, MD(Emergency Medicine),
Fellow of Academic College of Emergency Experts (FACEE),
Fellowship in Intensive Care Medicine (FICM).
Head of the Department
Department of Emergency Medicine
MOSC Medical College Hospital, Kolenchery, Ernakulam, Kerala
Lead, National EM Residency Network,
Emergency Medicine Association (EMA) of India

2.  62 / M, K/C/O HTN, DM
 Chest pain (L), sweating
 Vital signs are:
PR = 110/mt , R = 30/mt , BP = 120/60mm Hg.
What do you do next….??????????
CASE SCENARIO
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ECG & ACS - Dr. Ajith Venugopalan, EM, Kerala

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4. CLASSIFICATION OF ACS
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5. ECG IN STEMI
 Definition of STEMI –
 New ST elevation at the J point in two contiguous leads of >0.1
mV in all leads other than leads V2-V3 –
 For leads V2-V3 the following cut points apply:
 ≥0.2 mV in men ≥40 years, ≥0.25 mV in men < 40years
 >0.15mv in women.
 Other conditions which are treated as a STEMI –
 New or presumed new LBBB
 Isolated posterior MI
 The presence of reciprocal ST depression helps confirm the diagnosis
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ECG & ACS - Dr. Ajith Venugopalan, EM, Kerala

6. LATERAL
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7. LOCALIZATION OF INFARCTION – LEADS CONCERNED
 Septal (V1- V2)
 Anterior (V3- V4)
 Lateral (I & aVL, V5 & V6)
 Inferior (II, III, aVF)
 Right ventricular (V1, V4R)
 Posterior (V7-9),
 In V1 to V2
 Dominant R wave (R/S ratio > 1) in V2
 Horizontal ST depression
 Tall, broad R waves (>30ms)
 Upright T waves
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ECG & ACS - Dr. Ajith Venugopalan, EM, Kerala

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DIAGNOSIS
Inferior, Lateral Wall STEMI

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10. INFERIO
R WALL
LATERAL
WALL
ANTERIOR
WALL
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11. ST SEGMENT ELEVATION
 Acute myocardial infarction
 Coronary vasospasm
(Printzmetal’s angina)
 Pericarditis
 Benign early repolarization
 Left bundle branch block
 Left ventricular hypertrophy
 Ventricular aneurysm
 Brugada syndrome
 Ventricular paced rhythm
 Raised intracranial pressure
 Takotsubo Cardiomyopathy
ECG & ACS - Dr. Ajith Venugopalan, EM, Kerala

12. ST SEGMENT DEPRESSION
 Myocardial ischaemia /
NSTEMI
 Reciprocal change in STEMI
 Posterior MI
 Right bundle branch block
 Left bundle branch block
 Left ventricular hypertrophy
 Ventricular paced rhythm
 Digoxin effect
 Hypokalaemia
 Supraventriculartachycardia
 Right ventricular hypertrophy
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ECG & ACS - Dr. Ajith Venugopalan, EM, Kerala

13. PATHOLOGICAL T WAVE
More than half the size of the preceding QRS complex
Tall T wave:
 Hyperkalaemia –tall tented T
 Acute MI – Hyperacute T waves
 Prinzmetal angina
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ECG & ACS - Dr. Ajith Venugopalan, EM, Kerala

14. T WAVE INVERSION
 Normality
 Ischaemia
 Ventricular hypertrophy
 Bundle branch block
 Digoxin treatment.
 Idiopathic apical hypertrophy (a
rare form of hypertrophic
cardiomyopathy)
 Mitral valve prolapse
 Digoxin effect
 RVH and LVH with "strain" 14
ECG & ACS - Dr. Ajith Venugopalan, EM, Kerala

15. OTHER DANGEROUS T WAVE CHANGES
 Biphasic T wave
 Deep T wave inversion
 Remember Wellens T waves
ECG & ACS - Dr. Ajith Venugopalan, EM, Kerala

16. …..THANK YOU…..
Dr. Ajith Venugopalan
9496339347
ajith.v123@gmail.com