12 Lead STEMI Mimics

Objectives
Identify ECG findings that imitate or
conceal STEMI
Significance of bundle branch blocks
(BBB) in the acute coronary syndrome
patient
Cardiac conditions that can cause ST
abnormalities in the absence of ACS

Bundle Branch Blocks

Produce ECG
changes that can
imitate or conceal
the ECG changes
that are
associated with
Acute Coronary
Syndromes (ACS)

Bundle Branch Anatomy

Bundle Branch Block Significance

In cases where an acute MI produces a BBB the
mortality rate is higher then in patients without a
Important to know:
BBB
When
It is not
the presence
of block
the BBB
increases
a bundle
branch
is that
present
on the
mortality
but the
that thea necrosis
is more
12 lead ECG
tryfact
to obtain
copy of an
old 12
widespread
lead
ECG if possible in order to determine if the
BBBwith
is old
or new
In an ACS patient
a new
or presumed new
BBB acute reperfusion therapy is indicated

Recognition of BBB
Wide QRS
(greater then
0.12 seconds or
3 small squares)
Supraventricular
rhythm
If both of the
above criteria
are met suspect
a BBB

> 3 small squares

P wave

Right or Left BBB?

Look at V1 (this method

only works in V1)
Does the QRS meet the
criteria for BBB?
If it does follow the steps
below:
Find the J point
Draw a line into the centre
of the QRS
Draw a line back towards
complex point
Shade the area in
If the arrow points up it is a
right BBB, if the arrow
points down it is a left BBB

Left BBB

Right BBB

Practice ECG # 1

Look for signs of a BBB (wide QRS with P waves present)

Determine if the BBB is a left BBB or a right BBB
Are there signs of ST elevation present?

Answer ECG # 1

P wave

QRS > 0.12 seconds

P waves present
In V1 arrow points down
Left BBB
No ST elevation present

QRS > 0.12s

Practice ECG # 2

Look for signs of a BBB (wide QRS with P waves present)

Determine if the BBB is a left BBB or a right BBB
Are there signs of ST elevation present?

Answer ECG # 2

QRS is wide
No P waves present (this is a ventricular rhythm)
Not a bundle branch block
No signs of ST elevation
This is ventricular tachycardia

Practice ECG # 3

Look for signs of a BBB (wide QRS with P waves present)

Determine if the BBB is a left BBB or a right BBB
Are there signs of ST elevation present?

Answer ECG # 3

Wide QRS and P waves are present

Arrow in V1 points up
No ST elevation
This is a right BBB

Other conditions that can mimic or

conceal ST elevation

Ventricular rhythms (will not be covered here):

Paced rhythms
Idioventricular rhythms
Ventricular tachycardia
Premature ventricular complexes
Other conditions:
Left ventricular hypertrophy
Ventricular aneurysm
Benign early repolarization
Pericarditis
Hyperkalemia

Left Ventricular Hypertrophy (LVH)

Enlargement of the left ventricle often caused by uncontrolled

hypertension
Recognized by an increase in the amplitude of the QRS complex
In LVH the QRS is narrow but has a much greater amplitude then QRS
complexes of a normal heart
Can cause the ST segment to appear elevated in some leads and to
down slope in other leads

When to Suspect LVH

To determine if LVH is a possibility do the following:

Pick the deepest QRS from V1 or V2, in this ECG it is V2
Pick the tallest QRS from V5 or V6, in this ECG it is V5
Count the small boxes for both V2 QRS and V5 QRS (V2 = 30, V5 =
35)
Add the number together, if it is greater then 35 suspect LVH (65 for
this ECG therefore LVH is suspected)

Ventricular Aneurysm

May cause ST elevation in leads V1 through V4 in the absence of an

acute cardiac condition
Generally result from an area of necrosis due to an old infarct which
causes the ventricle to bulge out during ventricular contraction

Ventricular Aneurysm

Benign Early Repolarization

This is a normal ECG variation

Completely healthy people can have an ECG that shows ST elevation
and tall T waves
This condition typically occurs in young healthy males
The J point and ST segment are elevated and usually have a fish
hook appearance
Tall upright T waves may also be present

Fish hook

Important to know: presence of a fish

hook J point and ST segment does not
rule out ACS as some ACS patients will
also have a fish hook

Pericarditis

An inflammation of the pericardial sac caused by a bacterial or viral infection or a

metabolic condition
Causes diffuse ST segment changes and may also have a fish hook
appearance as in early repolarization
Different pain pattern then in ACS patients (classic pericarditis pain pattern):

Sharp knife like

Very localized
May radiate to base of neck or between shoulder blades
Affected by movement, respiration etc
Often pain improves when patient leans forward
Pain worsens when supine or semi-fowlers

Hyperkalemia

Changes to ECG vary depending on potassium level

Tall peaked T waves are present throughout the ECG in mild cases
With higher potassium levels the QRS will be wide and the ST
segment will disappear; P waves will also begin to flatten
In severe cases of hyperkalemia P waves will disappear entirely and
the QRS will widen and join the T wave to form a Sine wave

Tall peaked T wave

Sine wave

For More Information on 12 Leads

For more information on ST abnormalities:
http://www.madsci.com/manu/ekg_st-t.htm
For more information on 12 lead ECG and patient
presentations:
http://www.madsci.com/manu/indexekg.htm
ECG Learning Centre:
http://library.med.utah.edu/kw/ecg/index.html

Thank You for participating in

Sunnybrook Osler Centre for
Prehospital Care online education!
If you have any questions please
bring them with you to class!