ACLS Revision: Subtle ECG findings in ACS

acs

  • ST-segment elevation in lead aVR portends a worse prognosis in ACS and often predicts the need for CABG.
  • Hyperacute T-waves are not necessarily tall, and small T-waves can still be hyperacute when paired with a low-amplitude QRS complex.
  • The tall T-waves associated with hyperkalemia are sharp, pointy, symmetric, and have a narrow base.
  • When in doubt, get serial ECGs (every 15 minutes) and use adjunctive information.

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The Elevated Troponin

 

Causes of Elevated Troponin

Noncardiac Causes Cardiac Causes
Acute Noncardiac Critical Illness Acute and Chronic Heart Failure
Acute Pulmonary Edema Acute Inflammatory Myocarditis or Endocarditis/Pericarditis
Acute Pulmonary Embolism Aortic Dissection
Cardiotoxic Drugs Aortic Valve Disease
Stroke, Subarachnoid hemorrhage Apical Ballooning Syndrome
Chronic Obstructive Pulmonary Disease Bradyarrhythmia, Heart Block
Chronic renal failure Cardiac contusion from trauma
Extensive Burns Cardiac surgery, Post-percutaneous Coronary Intervention, Endomyocardial biopsy
Infiltrative Disease (Amyloidosis) Cardioversion
Rhabdomyolysis with Myocyte Necrosis Direct Myocardial Trauma
Sepsis Hypertrophic Cardiomyopathy
Sever Pulmonary Hypertension Tachycardia/Tachyarrhythmia, Bradyarrhythmia
Strenuous Exercise/Extreme Exertion  
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Hidden heart attacks…

Criteria for diagnosis of posterior STEMI include:

  • ST-depression ≥0.5mm in leads V1-V3.
  • Associated T-waves are either upright or inverted.
  • Appearance of tall R-waves in V1-V2 (may be delayed).
  • Recommended: posterior chest wall leads (V7-V9 ≥0.5 mm* ST-elevation).
    *may be decreased secondary to increased distance of posterior leads from heart.