Chest Pain and syncope

Dr Cynthia Lim, Dr Peter Jordan, Dr Megan Robb

ACS - STEMI

• If there is ST elevation, it will be a STEMI if:• Any ST dep except V1 or aVR (allowed in acute

pericarditis)• ST elevation III > II• Horizontal or convex up ST elevation• New Q waves

ACS - Pericarditis

• If ST elevation, pericarditis is more likely if:• PR depression multiple leads

– Only reliably seen viral– transient

• Low voltage and tachycardia = large pericardial effusion

• Use T-P as baseline (not P-P interval)• If in doubt serial ECGs, seek opinion

Normal variant ST elevation

• ST elevation may occur as a normal variant and represents EARLY REPOLARISATION

• Seen in young adults and people of African descent

• ST elevation may also indicate other pathology

BENIGN features •Concave up morphology• Large symmetrical T-waves• Notch at R and S wave• J-point elevation (point at where the ST segment begins.)

Pick the problem… (What’s it called?)

Wellen’s Syndrome: Deep T-wave inversion or biphasic T-waves in the absence of pain in V2 – V5.

Wellen’s Syndrome• Pattern of ECG T-wave

changes which is associated with critical proximal LAD stenosis

• Presence may predict proximal LAD occlusion

• Found in patients with recent history of chest pain but changes present in absence of pain

• EST may be fatal• Strong indicator for AG

30 yr old male with syncope

Brugada Syndrome

Brugada Syndrome

• ECG Findings– Three types – ST elevation v1 – v3 >

2mm– Complete or incomplete

RBBB• T-wave α types

– 1. Inverted– 2. Biphasic– 3. Upright

Brugada – Why do we care?

• Predisposition to polymorphic ventricular tachycardia• Identification and treatment with AICD may prevent a young sudden cardiac death

Arrthymogenic RV cardiomyopathy/dysplasia - inverted T waves in leads V1 through V5. Arrowheads point to late RV activation, called an epsilon wave

25 year old with syncope on exercising

When to refer cardiac syncope to ED

• All 2nd degree and 3rd degree heart blocks

• All trifascicular blocks

• All rapid AF >120

• All SVTs in not terminated by Valsalva manouvre

• “funny looking” ST/T segments – discuss/fax

• Asymptomatic patients with WPW, ST changes can be referred to cardiology OPA