Leanna R. Miller, RN, MN, CCRN-CSC, PCCN-CMC, CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN

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ST Segment Changes: Identifying MI Mimics. Leanna R. Miller, RN, MN, CCRN-CSC, PCCN-CMC, CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN. ST Segment Changes: Identifying MI Mimics. Objectives Evaluate common abnormalities that mimic myocardial infarction .
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ST Segment Changes: Identifying MI MimicsLeanna R. Miller, RN, MN, CCRN-CSC, PCCN-CMC, CEN, CNRN, CMSRN, NPEducation Specialist LRM ConsultingNashville, TNST Segment Changes: Identifying MI Mimics
  • Objectives
  • Evaluate common abnormalities that mimic myocardial infarction.
  • Identify the criteria for pericarditis and evidence – based interventions.
  • Differentiate between pulmonary embolus and myocardial infarction using diagnostic criteria.
  • ST Segment Changes: Identifying MI Mimics
  • Acute Coronary Syndromes
  • Unstable Angina
  • Non ST segment Elevation MI (NSTEMI)
  • ST segment Elevation MI (STEMI)
  • ST Segment Changes: Identifying MI MimicsST Segment Changes: Identifying MI Mimics
  • Acute Coronary Syndromes
  • Clinical Symptoms
  • typical
  • atypical
  • ST Segment Changes: Identifying MI Mimics
  • Acute Coronary Syndromes
  • Diagnostics
  • Echocardiography
  • Lab
  • ABGs
  • H & H
  • enzymes
  • ST Segment Changes: Identifying MI Mimics
  • Acute Coronary Syndromes
  • Diagnostics
  • ECG (12 or 15 lead)
  • T wave inversion
  • ST segment elevation
  • Q wave
  • reciprocal ST segment
  • depression
  • ST Segment Changes: Identifying MI MimicsST Segment Changes: Identifying MI MimicsST Segment Changes: Identifying MI MimicsST Segment Changes: Identifying MI MimicsVariation to ST – Segment ElevationST Segment Changes: Identifying MI MimicsST Segment Changes: Identifying MI MimicsHigh acute risk factors for progression to myocardial infarction or death
  • recurrent chest pain at rest
  • dynamic ST-segment changes: ST-segment depression > 0.1 mV or transient (<30 min) ST-segment elevation >0.1 mV
  • elevated Troponin-I, Troponin-T, or CK-MB levels
  • ST Segment Changes: Identifying MI MimicsHigh acute risk factors for progression to myocardial infarction or death
  • hemodynamic instability within the observation period
  • major arrhythmias (ventricular tachycardia, ventricular fibrillation)
  • early post-infarction unstable angina
  • diabetes mellitus
  • ST Segment Changes: Identifying MI MimicsST Segment Changes: Identifying MI MimicsST Segment Changes: Identifying MI MimicsST Segment Changes: Identifying MI MimicsST Segment Changes: Identifying MI MimicsST Segment Changes: Identifying MI MimicsST Segment Changes: Identifying MI Mimics
  • Acute Pericarditis
  • Introduction
  • causes physical discomfort
  • predisposition to tachydysrhythmias
  • ST Segment Changes: Identifying MI Mimics
  • Acute Pericarditis
  • ECG Criteria
  • ST segment elevation
  • PR segment depression
  • T wave flattening or inversion
  • atrial dysrhythmias
  • ST Segment Changes: Identifying MI Mimics
  • Acute Pericarditis
  • ST segment elevation
  • not isolated or discrete segments
  • upward concavity
  • may be notching at the junction of
  • QRS and ST segment
  • no reciprocal ST segment depression
  • ST Segment Changes: Identifying MI Mimics
  • Acute Pericarditis
  • PR interval
  • interval between end of P wave and
  • beginning of QRS may be depressed
  • most often seen in lead II and V
  • leads may be only ECG finding
  • ST Segment Changes: Identifying MI Mimics
  • Acute Pericarditis
  • T wave flattening or inversion
  • no T wave inversion during acute phase
  • uncomplicated pericarditis: negative
  • T waves only occur in leads which usually
  • have negative T waves (aVR & V1)
  • ST Segment Changes: Identifying MI Mimics
  • Acute Pericarditis
  • Atrial dysrhythmias
  • SVT in postoperative open heart patient
  • treat with low dose steroids
  • ST Segment Changes: Identifying MI MimicsST Segment Changes: Identifying MI Mimics
  • Acute Pericarditis
  • Complications (pericardial effusion)
  • dampening of electrical output
  • low voltage in all leads
  • ST segment & T wave changes
  • ST Segment Changes: Identifying MI Mimics
  • Acute Pericarditis
  • Complications (pericardial effusion)
  • freely rotating heart produces
  • electrical alternans
  • ST Segment Changes: Identifying MI Mimics
  • Dressler’s Syndrome
  • Introduction
  • postmyocardial infarction syndrome
  • autoimmune process
  • ST Segment Changes: Identifying MI Mimics
  • Dressler’s Syndrome
  • Clinical Presentation
  • low – grade fever
  • chest pain (worsens with deep
  • breath; lessens with sitting up
  • and leaning forward)
  • pericardial friction rub
  • ST Segment Changes: Identifying MI Mimics
  • Dressler’s Syndrome
  • 12 – lead ECG
  • diffuse ST segment elevation across the precordial leads
  • ST Segment Changes: Identifying MI Mimics
  • Dressler’s Syndrome
  • Treatment
  • corticosteroid administration
  • monitor for complications (effusion)
  • ST Segment Changes: Identifying MI Mimics
  • Pulmonary Embolus
  • Introduction
  • sudden massive PE produces ECG changes
  • must get 12 – lead to rule out MI
  • ST Segment Changes: Identifying MI Mimics
  • Pulmonary Embolus
  • ECG Findings
  • RVH with strain
  • RBBB pattern in V1
  • large S wave in Lead I; large Q wave in Lead
  • III (S1Q3 pattern)
  • ST Segment Changes: Identifying MI MimicsST Segment Changes: Identifying MI MimicsST Segment Changes: Identifying MI Mimics
  • Ventricular Aneurysm
  • Introduction (etiology)
  • myocardial infarction
  • congenital
  • cardiomyopathy
  • inflammatory
  • idiopathic
  • ST Segment Changes: Identifying MI Mimics
  • Ventricular Aneurysm
  • Introduction
  • infereolateral wall of LV
  • symptoms include CHF & exercise –
  • induced syncope (VT)
  • ST Segment Changes: Identifying MI Mimics
  • Ventricular Aneurysm
  • ECG Findings
  • persistent ST segment elevation
  • small q wave in II, III, & aVF
  • sustained VT with RBBB morphology
  • ST Segment Changes: Identifying MI MimicsST Segment Changes: Identifying MI MimicsST Segment Changes: Identifying MI MimicsST Segment Changes: Identifying MI Mimics
  • Ventricular Aneurysm
  • Treatment
  • surgical resection
  • antidysrhythmics
  • anticoagulants
  • treat heart failure
  • ablation therapy
  • ST Segment Changes: Identifying MI MimicsST Segment Changes: Identifying MI Mimics
  • Left Bundle Branch Block (LBBB)
  • QRS duration > 0.12 second
  • absence of septal q waves and S wave
  • in I, aVL, & V5 – 6 (+ complex usually
  • notched)
  • broad QS or rS in V1 – 3(- complex)
  • ST Segment Changes: Identifying MI Mimics
  • Left Bundle Branch Block (LBBB)
  • S – T, T wave changes in leads I,
  • aVL & V5 – 6 (T wave opposite QRS)
  • delayed intrinsicoid deflection over
  • left ventricle (V6); normal over V1
  • ST Segment Changes: Identifying MI Mimics
  • Left Bundle Branch Block (LBBB)
  • hypertensive heart disease
  • aortic stenosis
  • degenerative changes of the conduction
  • system
  • coronary artery disease
  • ST Segment Changes: Identifying MI MimicsST Segment Changes: Identifying MI MimicsST Segment Changes: Identifying MI MimicsST Segment Changes: Identifying MI MimicsST Segment Changes: Identifying MI MimicsST Segment Changes: Identifying MI MimicsLBBB with Acute Myocardial InfarctionST Segment Changes: Identifying MI MimicsLeft Ventricular HypertrophyST Segment Changes: Identifying MI MimicsST Segment Changes: Identifying MI MimicsLeft Ventricular HypertrophyST Segment Changes: Identifying MI Mimics
  • Brugada Syndrome
  • autosomal dominant inheritance (SCN5A) gene
  • sodium channel involvement in 25% of the patients
  • Asian populations (58%)
  • high incidence of polymorphic ventricular tachycardias
  • ST Segment Changes: Identifying MI Mimics
  • Brugada Syndrome
  • found in right precordial leads
  • prominent J wave
  • ST – segment elevation in the absence of structural heart disease
  • three types
  • ST Segment Changes: Identifying MI Mimics
  • Brugada Syndrome
  • Type I: ST – segment elevation is triangular and T waves may be inverted in V1 – V3
  • Type II: downward displacement of ST – segment (does not reach baseline)
  • Type III: middle part of ST segment touches baseline
  • ST Segment Changes: Identifying MI MimicsST Segment Changes: Identifying MI MimicsBrugada SyndromeST Segment Changes: Identifying MI MimicsLBBB
  • Infarction Resemblance
  • ST segment elevation in the negatively deflected leads, (V1 – V3)
  • QS complexes in the negatively deflected leads, (V1 – V3)
  • Recognition
  • Wide QRS
  • QS in V1
  • ST Segment Changes: Identifying MI MimicsVentricular Rhythms
  • Infarction Resemblance
  • ST segment elevation in the negatively deflected leads, (V1 – V3)
  • QS complexes in the negatively deflected leads, (V1 – V3)
  • Recognition
  • Wide QRS following pacer spike
  • Negative V1 (RV paced)
  • ST Segment Changes: Identifying MI MimicsLVH
  • Infarction Resemblance
  • ST segment elevation in the negatively deflected leads, (V1 – V3)
  • Recognition
  • Choose deepest S wave from V1 and V2
  • Choose tallest R wave from V5 and V6
  • Add deflections of tallest R wave and deepest S wave
  • Suspect LVH if total is > 35
  • ST Segment Changes: Identifying MI MimicsPericarditis
  • Infarction Resemblance
  • ST segment elements in multiple leads
  • Recognition
  • ST segment elevation not in anatomical grouping
  • PR segment depression
  • Notching of the J point
  • ST Segment Changes: Identifying MI MimicsAcute Pulmonary Emboli
  • Infarction Resemblance
  • RVH with strain pattern
  • RBBB pattern in V1
  • S1Q3 on frontal plane
  • Recognition
  • Patient is symptomatic with atypical cardiac pain
  • Elevated BMP
  • r/o with spiral CT/angiogram
  • ST Segment Changes: Identifying MI MimicsVentricular Aneurysm
  • Infarction Resemblance
  • High risk for ventricular dysrhythmias (VT with RBBB pattern)
  • Inferolateral MI
  • Persistent ST segment elevation
  • Small q wave in II, III, aVL
  • Recognition
  • Structural abnormality on ECHO
  • CHF & exercise – induced syncope (VT)
  • ST Segment Changes: Identifying MI MimicsBrugada Syndrome
  • Infarction Resemblance
  • Ventricular dysrhythmias (polymorphic VT)
  • ST segment elevation in right precordial leads
  • Recognition
  • Autosomal dominant
  • Asian culture
  • No structural abnormality noted on ECHO
  • ST Segment Changes: Identifying MI Mimics
  • Prominent J with ST segment elevations
  • septal MI
  • RV cardiomyopathy
  • pericardial effusion
  • hypercalcemia
  • ST Segment Changes: Identifying MI Mimics
  • Prominent J with ST segment elevations
  • hyperkalemia
  • acute pulmonary embolism
  • subarachnoid hemorrhage
  • tricyclic antidepressant intoxication
  • ST Segment Changes: Identifying MI MimicsST Segment Changes: Identifying MI Mimics
  • In Conclusion
  • is the patient having a MI?
  • a variety of conditions can mimic infarction
  • ST segment changes
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