ECG:

Acute coronary syndromes

Cardiovascular disease
• Commonest cause of
death
• ACS Common
admissions
• 33,623 in year 2000
• Increase with age
 Coronary artery disease
Plaque disruption
CHRONIC Accelerated progression
ACUTE

ATHERO-SCLEROSIS ATHERO-THROMBOSIS

RISK
FACTORS

YEARS MINUTES
Asymptomatic Acute coronary syndromes
Silent ischaemia Sudden Cardiac Death
Stable angina
Acute Coronary Syndrome in Young patients under 45 years old

ACUTE CORONARY SYNDROME (ACS)

NO ST ELEVATION ST ELEVATION

NSTEMI STEMI*

UNSTABLE NQMI QwMI

ANGINA Myocardial Infarction
SPECTRUM OF ACS

Modified from Antman EM, Braunwald E. Acute myocardial infarction

 Electrocardiography
• ST elevation:
– Limb > 1 mm;
– Precordial > 2 mm
– LBBB new or presumably new
• ST segment depression > 0.05 mV
• T-wave inversion – marked >0.2 mV symmetrical T-wave
inversion in precordial leads
• Bundle branch block
• Arrhythmias
• Serial assessment
– Rest vs. Exercise
– At time of symptom vs. absence
Hallmark of ischaemia-infarction
 “Rule in AMI” ECG criteria
These 3 characteristics have independent predictive
value and prognostic value;
Recommended for rapid triage:

• ST elevation ≥0.1mV (1mm) in leads (+)QRS

• ST depression ≥0.1mV (1mm) in V1-V3
• ST elevation ≥0.5mV (5mm) in leads with (–)QRS

New or presumably new LBBB coupled with typical

ischaemic history
 Posterior V7-V9 (V1-V3)
Anterior V1-V3
Superior (aVR, aVL)

Lateral I,
aVL
(Medial-RV)
V3R-V6R

Inferior II, III, avF

Apical V5-V6
Beyond standard “12-lead-ECG”
V7 Post-Axillary V9 V8 V7
V8 Mid-scapular
V9 Para-vertebral

V5R
V4R
V3R
 ACS: ECG can be “normal”

50yo hypertensive, smoker

1-2 hr of “stuttering” chest discomfort, palpitation
 ECG changes can be subtle!

• 45yo female diabetic-5yr

• Woken up at 4am with SOB, nausea
 Dynamic changes: T waves

• 75yr female hypertensive

• “Atypical” chest discomfort at rest and exertion
 Previous inferior AMI: Q waves

• 52yo male smoker, hypercholesterolaemia, FHx

• 1 hr chest discomfort on exertion, similar episode 3 days ago, pain
partially relieved by GTN
 Dynamic changes: ST segment

• 40yr smoker executive

• Chest tightness during company meeting, on-off for 2 hours, 5-10min
 STEMI in evolution

• 53yr woken at 5.00am with “choking”

• Arrive at hospital within 30minutes (no traffic jam!)
 Tachycardia ↔ Ischaemia

• 75yo hypertensive diabetic

• 1hr of subacute breathlessness and palpitation
 ST-T changes: ACS?

80yr hypertensive
“Off-her-feet” for 1-2week, found in confused state this morning.
 Chest pain after exertion

• 60yo smoker, FHx, 2mo of anginal chest pain

• Undergoes EST, terminated after chest discomfort at Stage 2, relief
partially with GTN….
 STEMI in evolution

• Admitted an hour ago … for chest “squeezing”, worse on

exertion, while in CCU…more chest pain
 Elevated J point ?STEMI

• 38yo athlete, smoker, FHx

• Chest discomfort after involved in motor vehicle accident
 STEMI? NSTEMI?

• 68yo smoker, hypercholesterolaemia

• Fainted after chest pain at coffee shop, arrived at A&E with chest pain
and sweating.
 Acute or old infarct?

• 70yo right inguinal hernia,

• Pre-operative ECG, repeat…..
 ST segments elevation

• 56yo acute chest discomfort on-and-off for 5 days

 ST segments elevation

• 24yo non-smoker, FHx

• Chest discomfort
 ST segments elevation

• 69yo pensioner
• “Gray-out” while boarding bus, brought in by passerby
• Fully conscious, laceration forehead
 STEMI?

• 54yo MA complaint of acute shoulder and chest pain while

lifting O2 cylinder; Rested for 10minutes, still feel “unwell”.
 STEMI?

• 43yo man acute chest tightness on way to work, drove to

nearest Clinic in town….
 Acute or Old infarct?

76yo male heavy smoker, hypertension, history of MI 1year ago

Acute onset chest pain started 6 hours ago..
 “Tombstones & Graves”

Acute chest pain ~ 1 hour

Infarct territory? Infarct related vessel?
 STEMI arrhythmia

Syncope after chest pain…

Infarct territory? Infarct related vessel?
 STEMI arrhythmia

Arrhythmia?
Infarct territory? Infarct related vessel?
 STEMI arrhythmia

Arrhythmia?
Infarct territory? Infarct related vessel?
 “Tombstones & Graves”

Acute chest pain ~ 1 hour

Infarct territory? Infarct related vessel?
 Right sided praecordial leads ECG

V6R----V3R

Sites for right-sided leads are the mirror image of those for the usual left-
sided leads: in the fifth right intercostal space, lead V4R is at the
midclavicular line, lead V5R is at the anterior axillary line and lead V6R is at
the midaxillary line.
 “Tombstones & Graves”

• Infarct territory, vessel?

 Acute or old infarct?

Incidental finding during routine ECG…

No recall of chest pain, history of dyspepsia…
 STEMI arrhythmia

• Infarct territory? Infarct related artery?

 STEMI complications

• Chest pain and lower back pain

• Onset 2 hours ago, during dinner..
Thank You 