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ST Segment Elevation

Laurențiu Lucaci
Laurențiu Lucaci
   | 14 oct. 2022
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Article Category: Review
Publié en ligne: 14 oct. 2022
Pages: 47 - 78
DOI: https://doi.org/10.2478/rjc-2022-0014
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© 2022 Laurențiu Lucaci, published by Sciendo
This work is licensed under the Creative Commons Attribution 4.0 International License.

Figure 1

ST segment deviations in direct and indirect leads.
ST segment deviations in direct and indirect leads.

Figure 2a

The layout of the ST elevations (RED) and of the reciprocal ST depressions (GREEN) due to single vessel occlusions of the left anterior descending artery (LAD), right coronary artery (RCA) and left circumflex artery (LCX), respectively. NDDO = non-dominant artery with distal occlusion, NDPO = non-dominant artery with proximal occlusion, DDO = dominant artery with distal occlusion, DPO = dominant artery with proximal occlusion. For each one of the following cases RCA-DPO and LCX-DPO, the versions where the result of subtraction of the ST elevations conveyed by diametrically opposite territories is NOT zero (diametrically opposite ST elevations do not nullify each other) are displayed (the last two charts from the last column).
The layout of the ST elevations (RED) and of the reciprocal ST depressions (GREEN) due to single vessel occlusions of the left anterior descending artery (LAD), right coronary artery (RCA) and left circumflex artery (LCX), respectively. NDDO = non-dominant artery with distal occlusion, NDPO = non-dominant artery with proximal occlusion, DDO = dominant artery with distal occlusion, DPO = dominant artery with proximal occlusion. For each one of the following cases RCA-DPO and LCX-DPO, the versions where the result of subtraction of the ST elevations conveyed by diametrically opposite territories is NOT zero (diametrically opposite ST elevations do not nullify each other) are displayed (the last two charts from the last column).

Figure 2b

The layout of the ST elevations (RED) and of the reciprocal ST depressions (GREEN) due to single vessel occlusions of the left anterior descending artery (LAD), right coronary artery (RCA) and left circumflex artery (LCX), respectively. NDDO = non-dominant artery with distal occlusion, NDPO = non-dominant artery with proximal occlusion, DDO = dominant artery with distal occlusion, DPO = dominant artery with proximal occlusion. For each one of the following cases RCA-DPO and LCX-DPO, the versions where the ST elevations conveyed by diametrically opposite territories cancel each other are displayed (the last two charts from the last column).
The layout of the ST elevations (RED) and of the reciprocal ST depressions (GREEN) due to single vessel occlusions of the left anterior descending artery (LAD), right coronary artery (RCA) and left circumflex artery (LCX), respectively. NDDO = non-dominant artery with distal occlusion, NDPO = non-dominant artery with proximal occlusion, DDO = dominant artery with distal occlusion, DPO = dominant artery with proximal occlusion. For each one of the following cases RCA-DPO and LCX-DPO, the versions where the ST elevations conveyed by diametrically opposite territories cancel each other are displayed (the last two charts from the last column).

Figure 3

Electrocardiographic locating algorithm of expected acute single coronary occlusion, based upon the highest ST segment elevation found in precordial leads. LAD = left anterior descending artery, OCC = occlusion, D1 = first diagonal artery, S1 = first septal artery, “<” = proximal to, “>” = distal to. (data according to references 3, 15, 17, 36–42)
Electrocardiographic locating algorithm of expected acute single coronary occlusion, based upon the highest ST segment elevation found in precordial leads. LAD = left anterior descending artery, OCC = occlusion, D1 = first diagonal artery, S1 = first septal artery, “<” = proximal to, “>” = distal to. (data according to references 3, 15, 17, 36–42)

Figure 4

Acute occlusion of a)PROXIMAL LAD b)before and c)after drug-eluting stent primary angioplasty, as seen in RAO view (dr. Alexandru Burlacu). Acute occlusion of d)DISTAL LONG LAD e)before and f)g)after drug-eluting stent primary angioplasty, as seen in RAO view (dr. Marius Adoamnei). RAO = right anterior oblique.
Acute occlusion of a)PROXIMAL LAD b)before and c)after drug-eluting stent primary angioplasty, as seen in RAO view (dr. Alexandru Burlacu). Acute occlusion of d)DISTAL LONG LAD e)before and f)g)after drug-eluting stent primary angioplasty, as seen in RAO view (dr. Marius Adoamnei). RAO = right anterior oblique.

Figure 5

Electrocardiographic locating algorithm of expected acute coronary single occlusion, based upon the highest ST segment elevation found in the inferior leads. RCA = right coronary artery, LCX = left circumflex artery. (data according to references 3, 15, 17, 36–42).
Electrocardiographic locating algorithm of expected acute coronary single occlusion, based upon the highest ST segment elevation found in the inferior leads. RCA = right coronary artery, LCX = left circumflex artery. (data according to references 3, 15, 17, 36–42).

Figure 6

Acute occlusions of a)PROXIMAL RCA b)before and c)after drug-eluting stent primary angioplasty, as seen in LAO view (dr. Dan Năstasă) and d)DISTAL RCA e)before and f)after drug-eluting stent primary angioplasty, as seen in LAO view (dr. Nicușor Lovin). LAO = left anterior oblique.
Acute occlusions of a)PROXIMAL RCA b)before and c)after drug-eluting stent primary angioplasty, as seen in LAO view (dr. Dan Năstasă) and d)DISTAL RCA e)before and f)after drug-eluting stent primary angioplasty, as seen in LAO view (dr. Nicușor Lovin). LAO = left anterior oblique.

Figure 7

Acute occlusion of a a)PROXIMAL left circumflex artery b)before and c)after the drug-eluting stent primary angioplasty, as seen in RAO view (dr. Dan Năstasă).
Acute occlusion of a a)PROXIMAL left circumflex artery b)before and c)after the drug-eluting stent primary angioplasty, as seen in RAO view (dr. Dan Năstasă).

Figure 8

Left ventricular wall segments blood supply versions (data according to references 42, 43).
Left ventricular wall segments blood supply versions (data according to references 42, 43).

Figure 9

Acute occlusion of the first diagonal artery.
Acute occlusion of the first diagonal artery.

Figure 10

Hyperacute T wave.
Hyperacute T wave.

Figure 11

a)”tombstoning” and b)”shark fin” configurations of the ischaemic ST segment elevation.
a)”tombstoning” and b)”shark fin” configurations of the ischaemic ST segment elevation.

Figure 12

ST-elevation acute myocardial infarction inferred from fulfilling modified Sgarbossa criteria 1 and 3 in a patient with left bundle branch block and anterior chest pain.
ST-elevation acute myocardial infarction inferred from fulfilling modified Sgarbossa criteria 1 and 3 in a patient with left bundle branch block and anterior chest pain.

Figure 13

Left main coronary trunk severe stenosis.
Left main coronary trunk severe stenosis.

Figure 14

Wellens syndrome a)b)electrocardiographic features and c)angiogram in a patient with proximal LAD severe stenosis, c)dilated later on and secured by drug-eluting stent deployment. (dr. Dan Năstasă).
Wellens syndrome a)b)electrocardiographic features and c)angiogram in a patient with proximal LAD severe stenosis, c)dilated later on and secured by drug-eluting stent deployment. (dr. Dan Năstasă).

Figure 15

a)de Winter ST-T pattern b)before and c)d)after the drug-eluting stent angioplasty (dr. Dan Năstasă) of a proximal left anterior descending artery occlusion.
a)de Winter ST-T pattern b)before and c)d)after the drug-eluting stent angioplasty (dr. Dan Năstasă) of a proximal left anterior descending artery occlusion.

Figure 16

Electrocardiographic image of a left ventricular anterior wall aneurysm.
Electrocardiographic image of a left ventricular anterior wall aneurysm.

Figure 17

Electrocardiographic course of a patient with Takotsubo cardiomyopathy.
Electrocardiographic course of a patient with Takotsubo cardiomyopathy.

Figure 18

Acute pericarditis.
Acute pericarditis.

Figure 19

Acute myocarditis featuring a)ST-elevation within the inferior leads in a young patient with chest pain and myocardial injury enzymes variation, against the background of normal CT angiographic appearance of subepicardial coronary arteries and b)c)MRI markings of myocardial oedema (dr. Anatolie Cazacu) with d)ST segment fallen to baseline three weeks later.
Acute myocarditis featuring a)ST-elevation within the inferior leads in a young patient with chest pain and myocardial injury enzymes variation, against the background of normal CT angiographic appearance of subepicardial coronary arteries and b)c)MRI markings of myocardial oedema (dr. Anatolie Cazacu) with d)ST segment fallen to baseline three weeks later.

Figure 20

Acute pulmonary embolism, displaying ST segment elevation within the precordial leads.
Acute pulmonary embolism, displaying ST segment elevation within the precordial leads.

Figure 21

The type 1 diagnostic electrocardiographic pattern of Brugada syndrome a)enhanced by 39°C fever, as well as b)diminished after fever remission under paracetamol, reinforced thereafter by a flecainide challenge test (by kind permission of dr. Mircea Balasanian, from his personal collection).
The type 1 diagnostic electrocardiographic pattern of Brugada syndrome a)enhanced by 39°C fever, as well as b)diminished after fever remission under paracetamol, reinforced thereafter by a flecainide challenge test (by kind permission of dr. Mircea Balasanian, from his personal collection).

Figure 22

Electrocardiographic pattern of early repolarization, showing J wave across lateral leads.
Electrocardiographic pattern of early repolarization, showing J wave across lateral leads.

Figure 23

Electrocardiogram in hyperkalaemia, revealing ST segment elevation in lead V1, following a wide and rightward shifted QRS complex, related to a rhythm presumably idioventricular in origin, alongwith high and sharply pointed T wave in V4–V6. The amplitudes alike of the S and T waves promote the automatic erroneous heart rate double counting (an event not specific to, but nevertheless possible in hyperkalaemia).
Electrocardiogram in hyperkalaemia, revealing ST segment elevation in lead V1, following a wide and rightward shifted QRS complex, related to a rhythm presumably idioventricular in origin, alongwith high and sharply pointed T wave in V4–V6. The amplitudes alike of the S and T waves promote the automatic erroneous heart rate double counting (an event not specific to, but nevertheless possible in hyperkalaemia).

Figure 24

ST elevation within the right precordial leads and wide QRS complex in sinus rhythm, alternating with episodes of accelerated idioventricular rhythm, against the background of a deliberate intoxication with flecainide.
ST elevation within the right precordial leads and wide QRS complex in sinus rhythm, alternating with episodes of accelerated idioventricular rhythm, against the background of a deliberate intoxication with flecainide.

Figure 25

Pseudo ST elevation in the inferior leads, created by the F wave of the atrial flutter.
Pseudo ST elevation in the inferior leads, created by the F wave of the atrial flutter.

The manifold of causes of pseudo-STEMI.

Types of single cause ST segment elevation.

Comparison between ST elevation in myocardial ischaemia, early repolarization and acute pericarditis.

TRANSMURAL MYOCARDIAL ISCHAEMIA (STEMI, VASOSPASTIC ANGINA, TAKOTSUBO CARDIOMYOPATHY, LEFT VENTRICULAR ANEURYSM) EARLY REPOLARIZATION (ER) ACUTE PERICARDITIS
PR SEGMENT DEPRESSION Any depth in atrial infarction, associated with abnormal P wave morphology Less than 1 mm, means early atrial repolarization Often present (wherefore invariably combined with PR elevation in aVR +/− V1), indicating subepicardial atrial lesion, at least 1 mm depth, mostly in DII, aVF, V4–V6
QRS COMPLEX As time goes by, QRS abates quickly in direct leads and elevates in reciprocal leads, while pathologic Q waves (or QS complexes) emerge in direct leads High within precordial leads and left unchanged in the long run Similar to that one before the pericarditis onset
ST SEGMENT ELEVATION (STE) ST/QRS AMPLITUDES RATIO High ratio in at least one lead, STE sometimes having the “tombstoning” pattern = as the ST segment elevates, it hides beneath its shadow the decreasing R wave, while becoming rectilineal or convex upwards by engulfing the T wave Small in any lead Small = normal
USEFUL ECG LEADS

CLUSTERED in at least two adjoining leads from the same group forecasting the occluded coronary artery;

DIFFUSE, for example in case of a long (wrapping) LAD, supplying the apical LV inferior wall

CLUSTERED: a)lateral leads (type 1), b)lateral and inferior leads (type 2);

DIFFUSE: lateral, inferior and V1–V3 leads (type 3)

 DIFFUSE (except aVR and V1, +/− DIII), hardly ever seen in aVL
SHAPE Concave upwards at first, fast increasing while becoming either upsloping or convex upwards, shortly thereafter Concave upwards (with three subtypes: dominant ascending, symmetric and dominant descending), and J point clearly outlined / notched / beclouded Concave upwards and dominant ascending, merged smoothly with the ascending limb of the T wave
ST AMPLITUDE AT J POINT

V2–V3: more than 2.5 mm in men under 40 years, more than 2 mm in men older than 40 and more than 1.5 mm in women, regardless of age;

Any other standard lead, except V2–V3: more than 1 mm for any gender, any age;

V7–V9: more than 0.5 mm;

V3R–V4R: more than 0.5 mm (in men under 30 years, greater than 1 mm);

 ST amplitude between 1 and 3 mm within at least two adjoining leads, outside V1, V2 and V3 (so as to avoid confusion with Brugada syndrome); At most 5 mm, highest in DII, V5, V6 (DII > DIII)
ST/T RATIO ST/T amplitudes ratio at least 0.25 Small ST/T amplitudes ratio în V6 ST / T ratio at least 0.25 in V4–V6
TIME DEPENDENCY

Fast increase;

Swift decrease toward baseline if timely coronary reperfusion, gradual decrease if late or no coronary reperfusion, or unchanged if dyskinesis / aneurysm of the infarcted wall (long lasting = “frozen” ST elevation, followed by small negative / small positive T wave)

 Dependent on autonomic tone: increased during heightened vagal tone and decreased during sympathetic stimulation Vanishes once inflammation goes away
RECIPROCAL ST DEPRESSION

Available in diametrically opposite leads;

Absent in case of a)distal occlusion of a long LAD and in b)ventricular aneurysm;

 present in aVR in 50% of cases Usually revealed in aVR +/− V1, sometimes as well in DIII, aVL
T WAVE POLARITY AND AMPLITUDE Normal polarity and getting taller at first, inverted and going deeper thereafter. Inversion begins when STE is still in place. Usually of normal polarity. Seldom its terminal side becomes negative and small throughout V3–V5 (+/−V1–V2), driven by changes in autonomic tone

Usually normal polarity and amplitude during STE;

Seldom terminal part small amplitude inversion during STE, but inversion AFTER ST falls to baseline is the rule
MORPHOLOGY Wide base, symmetric limbs Narrow base
QT INTERVAL Sometimes prolonged Normal QTc Normal QTc

Scenario of ST segment elevation and troponin variation over time.
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