Transcript ST Segment Elevation Syndromes and Chest Pain

Is He Having
The Big
One?
Sirous Partovi, M.D.
Department of
Emergency
Medicine
TTUHSC, El Paso
ECG #1- 68 year old with chest pain for 3 days
ECG #2- 66 year old man with 1 hour
history of chest pressure
ECG #3- 39 year old AAM with chest
pain, PMH HTN
ECG #4 - 62 year old with profuse
diaphoresis and vomiting
ECG #5-72 year old male- PMH: CRF,a-fib
presents with generalized weakness for 1 hour.
ECG #6- 45 year old female with onset of
chest discomfort 2 hours ago – PMH ?Cancer
ECG #7 – 50 year old man with crushing
substernal chest pain for 30 minutes
ECG #8- 72 year old female with history of
HTN found unconscious
ECG #9- 67 year old man with PMH of MI in
respiratory failure due to acute CHF
ECG #10- Chest pain radiating to the jaw in
a 41 year old woman
Objectives
 Understand
the etiology of chest pain
 Distinguish between Acute Coronary
events requiring thrombolysis and those
that do not.
 Recognize the more common conditions
that may cause a pseudo-infarction
pattern on ECG.
Chest Pain
 2%
of all ED visits
 10-20% are diagnosed with AMI
 1.7 million admissions to hospitals annually
 $5 Billion spent on admitted patients which
AMI was subsequently ruled out in
Chest Pain- AMI
 1.1
million cases of AMI annually
 50% present to EDs
 2%-8% rate of misdiagnosis
 11,000 missed diagnosis of MI per year
 20% of money awarded in malpractice
cases
Differential Diagnosis of
Chest Pain
Cardiac
Non-ischemic
 Ischemic
Pericarditis
 Angina
 Unstable
 AMI
angina
Aortic
dissection
Valvular
Myositis
Differential Diagnosis of
Chest Pain
Non-cardiac
 Gastroesophageal
Causes
GERD
 Esophageal spasm
 PUD
 Boerhaave’s Syndrome
 Cholecystitis

Differential Diagnosis of
Chest Pain
Non-cardiac
 Non-gastroesophageal
Pneumothorax
 Pulmonary embolism
 Musculoskeletal
 Somatoform disorders

Chest Pain-Diagnosis
 History
and Physical
 ECG
 Cardiac
serum markers
AMI- World Health Organization
(WHO) Definition

A combination of two of three
characteristics:
Typical symptoms (i.e., ischemic-type chest
discomfort)
 A rise and fall in serum cardiac markers
 Typical ECG pattern involving the development
of Q waves

Acute MI - History
 70%-80%
present with ischemic type CP
 Less than 25% of patients admitted to
hospital with ischemic-type CP are
diagnosed with AMI
 Unusual symptoms for AMI
Elderly
 Women
 Diabetics

Features of H&P That Increase the
Probability of AMI
Panju et al, JAMA. 1998;280:1256-1263
History and Physical
 Chest
pain radiating to both arms
 Third heart sound
 Hypotension
 Chest pain radiating to right shoulder
LR
7.1
3.2
3.1
2.9
Likelihood Ratio
Positive LR
 Odds that a patient with a positive test
result has the target disorder
Pos LR= Sensitivity/(1-Specificity)
Negative LR
 Odds that a patient with a negative test
result has the target disorder
Neg LR= (1-Sensitivity)/Specificity
Historical Features That Decrease the
Probability of AMI
Panju et al, JAMA. 1998;280:1256-1263
Quality of Chest Pain
 Pleuritic
 Sharp or stabbing
 Positional
 Reproduced by palpation
LR
0.2
0.3
0.3
0.2-0.4
ECG evolution in Q-wave
Myocardial Infarction
 Tall
peaked T-waves
 ST-segment elevation
 Appearance of abnormal Q wave
 Decrease of ST-segment elevation with
the beginning of T-wave inversion
 Isoelectric ST-segment with symmetrical
T-wave inversion
Tall T- Waves
 The
earliest sign of AMI
 Due to subendocardial ischemia
 Within minutes or hours after the onset
of chest pain
 Transient
 Most ECGs fail to show this pattern
ECG evolution in Q-wave
Myocardial Infarction
 Tall
peaked T-waves
 ST-segment elevation
 Appearance of abnormal Q wave
 Decrease of ST-segment elevation with
the beginning of T-wave inversion
 Isoelectric ST-segment with symmetrical
T-wave inversion
ST-Segment Elevation
 The
most common early ECG sign
 STE - specificity 91% , sensitivity 46%
 Mortality increases with the number of ECG
leads showing ST elevation
 STE decreases in the first 7-12 hours
 STE resolves within 2 weeks in 90% of IWMI,
but only in 40% of anterior MI
Reciprocal ST-Segment
Depression
 Seen
in up to 82%
 Marked early, 50% resolve within 24 hours
 Due to reciprocal electrical alteration
 Increases specificity of AMI to 99%
 Seen in 72% of IWMI
 Indicative of:



Larger AMI
Lower ventricular ejection fraction
Higher mortality
ECG evolution in Q-wave
Myocardial Infarction
 Tall
peaked T-waves
 ST-segment elevation represents a stage
beyond ischemia -i.e. injury
 Appearance of abnormal Q-wave
 Decrease of ST-segment elevation with
the beginning of T-wave inversion
 Isoelectric ST-segment with symmetrical
T-wave inversion
Abnormal Q-Waves
 Most
commonly presents while STsegment still elevated
 12-20% of Q-waves do not persist
 CHF is more common with persistent
Q-waves
ECG evolution in Q-wave
Myocardial Infarction
 Tall
peaked T-waves
 ST-segment elevation
 Appearance of abnormal Q wave
 Decrease of ST-segment elevation with
the beginning of T-wave inversion
 Isoelectric ST-segment with symmetrical
T-wave inversion
ECG evolution in Q-wave
Myocardial Infarction
 Tall
peaked T-waves
 ST-segment elevation represents a stage
beyond ischemia -i.e. injury
 Appearance of abnormal Q wave
 Decrease of ST-segment elevation with
the beginning of T-wave inversion
 Isoelectric ST-segment with symmetrical
T-wave inversion
Criteria for Thrombolysis
 ST
elevation (greater than 1 mm in two or
more contiguous leads), time to therapy 12
hours or less, age less than 75 years.
 Bundle branch block (obscuring ST-segment
analysis) and history suggesting acute MI.
AMI Diagnosis- ECG
Factors Influencing ECG Interpretation
 Clinical
observation of the patient
 Knowledge of clinical data
 Training and experience of interpreter
AMI Diagnosis- ECG
Gjorup et al, J Intern Med. 1992; 231: 407-412
 16
IM residents read 107 ECGs
 Looking for signs indicative of AMI
 Disagreement in 70% of the cases
AMI Diagnosis- ECG
Willems et al, NEJM. 1991; 325:1767-1773
8
cardiologists interpreted 1220 ECGS
 High interobserver agreement -  of 0.67
 125 ECGs read twice

Different diagnosis for 10%-23% of ECGs
AMI Diagnosis- ECG
Massel et al. Am Heart J. 2000;140:221-6
3
cardiologists - 75 ECGs
 2 occasions (within 7 days)
 First reading: Presence or absence of
thrombolysis eligibility criteria
 Second reading: criterion 1 plus the
subjective opinion that the changes
represented acute transmural injury
AMI Diagnosis- ECG
Interobserver variability in thrombolytic therapy eligibility
Is there 1 mm ST elevation?
Does this represent an AMI?
Agreement
kappa
Agreement
kappa
Rater 1 vs 2
93.3
86.2
94.7
88.2
Rater 2 vs 3
88.0
75.8
94.7
88.0
Rater 1 vs 3
86.7
72.9
94.7
88.2
Overall
78.2
88.5
Errors in AMI
 ECG
of a patient who is otherwise eligible
may be incorrectly interpreted as being
nondiagnostic
 ST-segment elevation may be erroneously
interpreted as suggesting an AMI, resulting
in the inappropriate overuse of
thrombolysis
Errors in AMI – Missed Diagnosis
 ECG
of a patient who is otherwise eligible
may be incorrectly interpreted as being
nondiagnostic
 ST-segment elevation may be erroneously
interpreted as suggesting an AMI, resulting
in the inappropriate overuse of
thrombolysis
Errors in AMI - Missed Diagnosis
McCarthy et al, Ann Emerg Med.1993;22:5795-82
 Rate
of missed AMI among 6 NE hospitals
 1050 patients with AMI

1.9% misdiagnosed
 25%
of the patients with missed AMI had
STE of at least 1 mm
 Death or severe complications in 25% of pts
Errors in AMI - Missed Diagnosis
Pope et al, NEJM 2000;342:1163-70
 10,689
patients, 10 hospitals (ACI-TIPI trial)
 17% had acute cardiac ischemia (ACI)
8% AMI
 9% UA

 6%
stable angina
 21% other cardiac diagnosis
 55% noncardiac diagnosis
Errors in AMI – Missed Diagnosis
Pope et al
 Of
894 AMI patients, 19 (2.1%) was missed
 8 (47%) had one of the following ECG
readings: LVH, LBBB, BER, pericarditis
 7 (41%) minor ST segment abnormality
with <1mm of ST segment deviation
 14 of 19 had NQWMI
Errors in AMI – Missed Diagnosis
Brady et al, AEM, April 2001
 11 ECGs with STE
 45 yo male with HTN, DM and chest pain
 458 EPs
Errors in AMI – Missed Diagnosis
Brady et al, AEM, April 2001
 Overall rate of correct
Errors in AMI
 ECG
of a patient who is otherwise eligible
may be incorrectly interpreted as being
nondiagnostic
 ST-segment elevation may be erroneously
interpreted as suggesting an AMI, resulting
in the inappropriate overuse of
thrombolysis
Errors in AMI - Over Diagnosis
Lee et al, Ann Int Med 1989;110:957-62.
 No
AMI in 25% of patients with acute chest
pain and ST-segment elevation
 For every 8 patients appropriately treated
with a thrombolytic agent 1 or 2 will be
treated unnecessarily
Errors in AMI-Over Diagnosis
Sharkey et al, Am J Cardiol 1994;73:550-3
 93 patients with chest pain receiving
thrombolytic therapy, AMI did not occur
in 10 (11%)
LVH- 30%
 BER- 30%
 IVCD- 30%

Impact of Errors
 Bleeding
consequences
Life-threatening bleed- 0.4%
 Moderate bleed- 5%

 Not
treating an eligible thrombolysis
candidate
 Financial consequences
 Missed AMI is the leading cause of
malpractice loss in the ED setting
Causes of ST Segment Elevation
Cardiac
 Acute myocardial infarction






Variant (Prinzmetal's) angina
Acute pericarditis
Left ventricular aneurysm
Left ventricular hypertrophy
Bundle branch blocks
Benign Early repolarization
Causes of ST Segment Elevation
Metabolic
 Hyperkalemia
 Hypothermia (Osborne or "J" waves)
 Hyperventilation
Causes of ST Segment Elevation
Miscellaneous
 Acute abdominal disorders (pancreatitis,
cholecystitis, peritonitis)
 Central nervous system hemorrhage
 Medications (type I anti-arrhythmic
agents, isoproterenol)
 Body habitus
 Idiopathic
Localization of Acute MI
LOCATION
ECG LEADS
INVOLVED
Anteroseptal
V1, V2
Anterior
V2, V4
Anterolateral
Extensive Anterior
Inferior
PROBABLE ARTERY INVOLVED
Proximal LAD septal
perforator
LAD or its branches
V4- V6, I, aVL Mid LAD or circumflex
V1-V6
Proximal LAD
II,II,aVF
RCA, circumflex, distal LAD
High lateral
I, aVL
Circumflex or branch of LAD
Posterior
V1, V2
Posterior descending
Right ventricle
V1, rV3- rV4
RCA
ECG #1- 32 year old with chest pain at a
party
Anterolateral MI
Anterolateral MI - II
Anterolateral MI - III
65 year old with acute chest pain
Anterior MI
Acute Anterior MI
Acute Anteroseptal MI
Acute Anterior MI
Acute Anteroseptal MI
53 year old with severe light headedness,
nausea, diaphoresis, and upper abdominal pain.
Bloods pressure 85/palp.
Acute Inferoposterior MI
R
R
R
R
R
Acute Lateral MI
ECG #4 - 62 year old with profuse
diaphoresis and vomiting
ECG #7 – Acute Posterior MI - Old inferior MI
Inferior MI
(MR# 866159) -77 year old male with chest pain
and palpitation
Anterior MI
LVH with ST-T Wave Changes
Left Ventricular Hypertrophy
Definition
 ECG
diagnosis: based on the increase of the QRS
voltage
 Possible LVH - only voltage evidence of LVH
 Definite LVH - voltage evidence of LVH
associated with ST-T wave changes (strain)
 Strain pattern – characterized by downsloping ST
depression with asymmetric, biphasic, or
inverted T wave (occurs in 70% of cases)
LVH With Strain and CAD
 50%
prevalence of demonstrated CAD in
asymptomatic hypertensive patients with
LVH and strain vs. 4% general population
 60% of patients with LVH and strain had
reversible perfusion defects on Thallium
scintigraphy
LVH
 ECG
is 93-96% specific and 12-29%
sensitive in diagnosing LVH
 Echocardiography- 86% specificity and
100% sensitivity for diagnosis of LVH
LVH
Otto LA et al, Ann Emerg Med 1994;23:17-24
 Prehospital
study of adult chest pain
patients with STE
 Majority did not have AMI
 LVH and LBBB were most common
LVH
Brady WJ, J Emerg Med
 STE
resulted from AMI in only 15%
 LVH was the most frequent cause of
this STE (30%)
LVH
Larsen et al, J Gen Intern Med 1994;9:666-673
 10%
of patients diagnosed in the ED with
acute ischemic heart disease have LVH
 Only 26% of these patients were found to
have unstable angina or AMI
 Physicians incorrectly interpreted the ECG
more than 70% of the time
LVH by Voltage Only
 Cornell


Criteria- RaVL+SV3
>24 mm in males
>20 mm in female
LVH by Voltage Only
 Other

commonly used voltage-based criteria
Precordial leads (one or more)
RV5 or V6 + SV1
 >35 mm if age> 30 years
 >40 mm if age 20-30 years
 >60 mm if age 16-19 years
Maximum R wave + S wave in precordial
leads >45 mm
RV5 > 26 mm
RV6> 20mm
LVH by Voltage Only
 Other

commonly used voltage criteria
Limb leads (one or more)
RaVL >12 mm
RI + SII >26 mm
RI >14 mm
SaVR >15 mm
RaVF >21 mm
LVH by Voltage
RV5+SV1=43mm
RV5= 37mm
LVH by Both Voltage and
ST-T Segment Abnormalities
 Voltage
criteria for LVH
 ST-T segment abnormalities
 ST segment and T wave deviation
opposite in direction to the major
deflection of QRS
ST segment depression in leads I, aVL, III, aVF
+/- V4-V6
 Subtle ST elevation (1-2 mm) in leads V1-V3
 Inverted T waves in leads I, aVL, V4-V6
 Prominent or inverted U waves

LVH by Both Voltage and
ST-T Segment Abnormalities
 Voltage
criteria for LVH
 ST-T segment abnormalities

ST segment and T wave deviation opposite in
direction to the major deflection of QRS
 ST
segment depression in leads I, aVL,
III, aVF +/- V4-V6
Subtle ST elevation (1-2 mm) in leads V1-V3
 Inverted T waves in leads I, aVL, V4-V6
 Prominent or inverted U waves

LVH by Both Voltage and
ST-T Segment Abnormalities
 Voltage
criteria for LVH
 ST-T segment abnormalities
ST segment and T wave deviation opposite in
direction to the major deflection of QRS
 ST segment depression in leads I, aVL, III, aVF +/V4-V6

 Subtle
ST elevation (1-2 mm) in leads V1-
V3
Inverted T waves in leads I, aVL, V4-V6
 Prominent or inverted U waves

LVH by Both Voltage and
ST-T Segment Abnormalities
 Voltage
criteria for LVH
 ST-T segment abnormalities
ST segment and T wave deviation opposite in
direction to the major deflection of QRS
 ST segment depression in leads I, aVL, III, aVF
+/- V4-V6
 Subtle ST elevation (1-2 mm) in leads V1-V3

 Inverted
T waves in leads I, aVL, V4-V6
 Prominent or inverted U waves
Romhilt and Estes LVH Point
Score System
 QRS
Voltage – 3 points for the presence of any 1
criteria



R or S in limb leads  20 mm
S in V1 or V2  30 mm
R in V5 or V6  30 mm
 Typical


ST-T repolarization abnormality
Without digitalis – 3 points
With digitalis – 1 point
 LAD
- 30° or more – 2 points
 QRS duration  0.09 sec – 1 point
 ID V5-6  0.05 sec – 1 point
 LAE – 3 points
LVH With ST-T Abnormalities
S in aVR > 14mm
R in I = 15mm
RV5>26mm
RV5+SV1=65mm
R in aVL + S in V3 >24mm
LVH With ST-T Abnormalities
34 year old AAM with chest pain-No PMH
Benign Early Repolarization
 First
described in 1936 by Shipley
 A normal variant- 1% general population
 Common in athletes
 BER-in adult ED chest pain patients ~13%
 BER is seen on ECGs 23-48% of adult ED
chest pain patients who have used
cocaine
Benign Early Repolarization
 Mean
age - 39 (16-80)
 Most commonly less than 50 years of
age- older than 70 years(3.5%)
 Seen in men much more often than
women
ECG Criteria For BER
 Elevated
take-off of ST segment at the J point
 Upward concavity of the initial portion of the ST
segment
 Notching or slurring on downstroke of R wave
 Symmetric, concordant T waves of large
amplitude
 Widespread or diffuse distribution of ST segment
elevation on the ECG - most commonly in leads
V2-V5, sometimes in inferior leads
 No reciprocal ST segment change
 relative temporal stability
J
point elevation- less than 3.5 mm
 ST segment appears as if it has been lifted
evenly upward
 STE is less than 2 mm in 80-90%
 Only 2% of cases STE is greater than 5 mm.
J point
ECG Criteria For BER
 Elevated
take-off of ST segment at the J point
 Upward concavity of the initial portion of the ST
segment
 Notching or slurring on downstroke of R wave
 Symmetric, concordant T waves of large
amplitude
 Widespread or diffuse distribution of ST segment
elevation on the ECG - most commonly in leads
V2-V5, sometimes in inferior leads
 No reciprocal ST segment change
 relative temporal stability
Upward concavity
ECG Criteria For BER
 Elevated
take-off of ST segment at the J point
 Upward concavity of the initial portion of the ST
segment
 Notching or slurring on downstroke of R wave
 Symmetric, concordant T waves of large
amplitude
 Widespread or diffuse distribution of ST
segment elevation on the ECG-most commonly
in leads V2-V5, sometimes in inferior leads
 No reciprocal ST segment change
 relative temporal stability
Tall symmetric
T wave
ECG Criteria For BER
 Elevated
take-off of ST segment at the J point
 Upward concavity of the initial portion of the ST
segment
 Notching or slurring on downstroke of R wave
 Symmetric, concordant T waves of large
amplitude
 Widespread or diffuse distribution of ST segment
elevation on the ECG - most commonly in leads
V2-V5, sometimes in inferior leads
 No reciprocal ST segment change
 relative temporal stability
Benign Early Repolarization
(BER)
Acute Pericarditis
Acute Pericarditis
 Stage
1- Concave up ST segment elevation
 Stage 2- ST segment normal, flattening of
the T waves
 Stage 3- T wave inversion without Q wave
formation
 Stage 4- Normalization of ECG
Acute Pericarditis- Other ECG
Clues
 Sinus
tachycardia
 PR depression early
 Low voltage QRS
 Electrical alternans if pericardial
effusion
BER or Pericarditis
 ST
segment elevation in the two syndromes is
similar
 PR segment in pericarditis is often depressed
 ST segment elevation in acute pericarditis tends
to be widespread across the ECG
 T waves in pericarditis frequently is of normal
amplitude and morphology, whereas the T wave
in BER is frequently altered
 The ratio of the ST segment elevation to the
height of the T wave (ST/T) is also a helpful
guide; a ratio greater than 0.25 in lead V6
strongly suggests pericarditis
BER or Pericarditis
 ST
segment elevation in the two syndromes is
similar
 PR segment in pericarditis is often depressed
 ST segment elevation in acute pericarditis tends
to be widespread across the ECG
 T waves in pericarditis frequently is of normal
amplitude and morphology, whereas the T wave
in BER is frequently altered
 The ratio of the ST segment elevation to the
height of the T wave (ST/T) is also a helpful
guide; a ratio greater than 0.25 in lead V6
strongly suggests pericarditis
BER or Pericarditis
 ST
segment elevation in the two syndromes is
similar
 PR segment in pericarditis is often depressed
 ST segment elevation in acute pericarditis tends
to be widespread across the ECG
 T waves in pericarditis frequently is of normal
amplitude and morphology, whereas the T wave
in BER is frequently altered
 The ratio of the ST segment elevation to the
height of the T wave (ST/T) is also a helpful
guide; a ratio greater than 0.25 in lead V6
strongly suggests pericarditis
BER or Pericarditis
 ST
segment elevation in the two syndromes is
similar
 PR segment in pericarditis is often depressed
 ST segment elevation in acute pericarditis tends
to be widespread across the ECG
 T waves in pericarditis frequently is of normal
amplitude and morphology, whereas the T wave
in BER is frequently altered
 The ratio of the ST segment elevation to the
height of the T wave (ST/T) is also a helpful
guide; a ratio greater than 0.25 in lead V6
strongly suggests pericarditis
Pericardial Effusion
Electrical Alternans
BER or AMI
 ST-T
wave complex waveform
 Reciprocal changes
 Evolutionary changes
BER or AMI
 ST-T
wave complex waveform
 Reciprocal changes
 Evolutionary changes
BER or AMI
 ST-T
wave complex waveform
 Reciprocal changes
 Evolutionary changes
LBBB
LBBB- ECG Criteria
QRS duration(  0.12 sec)
 Delayed onset of intrinsicoid deflection in leads
I,V5, V6
 Broad monophasic R waves in leads I, V5, V6
 Secondary ST & T wave changes opposite in the
direction to the major QRS deflection
 rS or QS complex in right precordial leads
 LAD may be present
 Prolonged
LBBB- ECG Criteria
QRS duration( 0.12 sec)
 Delayed onset of intrinsicoid deflection in leads
I,V5, V6
 Broad monophasic R waves in leads I, V5, V6
 Secondary ST-T wave changes opposite in the
direction to the major QRS deflection
 rS or QS complex in right precordial leads
 LAD may be present
 Prolonged
LBBB- ECG Criteria
QRS duration( 0.12 sec)
 Delayed onset of intrinsicoid deflection in leads
I,V5, V6
 Broad monophasic R waves in leads I, V5, V6
 Secondary ST & T wave changes opposite in the
direction to the major QRS deflection
 rS or QS complex in right precordial leads
 LAD may be present
 Prolonged
QS
QS
rS
LBBB With MI
 Fulfills
criteria for LBBB
 Three criteria (Sgarbossa criteria) with
independent value for diagnosing AMI:
ST elevation  1 mm concordant to the
major deflection of the QRS
 ST depression  1 mm in V1, V2, or V3
 ST elevation  5 mm discordant with the
major deflection of the QRS

LBBB with Inferolateral MI
ECG #2- 66 year old man with history of
LBBB and 1 hour history of chest pressure
LBBB and AMI
LBBB and AMI
Sgarbossa criteria
 96% specific
 Pos LR = 22
 Neg LR = 0.8
RBBB
RBBB- ECG Criteria
duration  0.12 sec
 Delayed onset of ID
 Increased amplitude of the R’ in V1-V2
 Wide, slurred S wave in leads I,V5,V6
 Secondary ST-T abnormality
 QRS
RBBB
 Most
patients with RBBB have CAD
 Many have no evidence of underlying
heart disease
 In patients with AMI, RBBB is present in
3-7% of cases
 In uncomplicated RBBB, there usually is
little ST-segment displacement
AMI in The Presence of RBBB
 RBBB
does not interfere with the
recognition of infarcts.
 Even in presence of RBBB and either
LAHB or LPHB, infarcts can be
evaluated normally-EXCEPT

True posterior MI
RBBB, Inferoposterior MI
RBBB+LAHB+
Anterolateral MI
RBBB+LPHB+
Anteroseptal
30 year old diabetic found unresponsive
Hyperkalemia
ECG #5-72 year old male, PMH: CRF and a-fib
presents with generalized weakness for 1 hour.
72 year old female found unresponsive
ECG and ICH
 Most
commonly SAH
 Altered autonomic tone as a mechanism
 Abnormalities include
ST-segment elevation or depression
 Large, wide, upright , or inverted T waves
 Long QT interval
 Prominent U wave

ICH
70 year old asymptomatic man with PMH of MI
75 year old man found unresponsive on a
park bench, on New Years Eve, in Fargo…
 Many
causes of STE
 Features that increase likelihood of AMI
New STE
 New Q waves
 Any STE
 New LBBB
