st t changes: ischemia, secondary,memory or something else
TRANSCRIPT
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ST T Changes: Ischemia, Strain, Secondary or Memory ?
Dr. Darshan Jhala,
M.D., D.M.(Card.),
Lilavati Hospital,
Nanavati Super Speciality Hospital,
BSES MG Hospital,
Mumbai.
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‘To A Man With A Hammer, Every Problem Is A Nail.’ • Mark Twain
• So
To A Cardiologist, Is Every ST Shift Ischemia/MI ?
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Why Is ST Segment Isoelectric and T Upright ? Phase 2 = ST Segment Phase 3 = T Wave
Endo. Endo. Depolarization Repolarization
Epi. Epi.
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Causes of ST Segment shift :
• Specific patterns of ST-T wave changes may be seen in association with various disease states.
• Ischemia
• Myocardial Injury
• Pericarditis
• LVH
• Intraventricular conduction Delays (RBBB, LBBB)’
• Aneurysm
• Persistent Juvenile t-wave pattern
• Early Repolarization
• ‘Memory’ Phenomenon
• Electrolyte abnormalities
• Post-cardiac surgical state
• Anemia
• Fever
• Acidosis or alkalosis
• Catecholamines
• Drugs
• Acute abdominal process
• Endocrine abnormalities
• Metabolic changes
• Cerebrovascular accidents
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What Is This ?
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Cardiac ‘Memory’ Effect (CM) :
• Cardiac memory (CM)
• refers to a specialized form of remodeling. It is characterized by an altered T wave on electrocardiogram (ECG) or
• vectorcardiogram recorded during sinus rhythm (or any
• rhythm with normal ventricular activation) and induced by
• a preceding period of altered electrical activation.
• CM has been described following stimuli such as
• electrical pacing, intermittent left bundle branch block, paroxysmal tachycardia, and preexcitation
Mechanism:
• Changes in AP configuration
• Ion Channel remodeling
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Clinical Implications Of CM :
• can confound the diagnosis of cardiac ischemia • (1) positive TaVL, • (2) positive or isoelectric TI • (3) maximal precordial TWI > TWI(III)
(92% sensitive and 100% specific for CM)
• ventricular pacing, long thought to be a “neutral” intervention with regard to cellular and subcellular function, in fact is a potent modulator of cellular processes.
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Why is a Normal ECG being shown over here ?
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ERS : ‘J’ Wave Syndrome :
• The ERS is commonly seen in athletes, cocaine users, HOCM,VSDs
• Prevalence varies between 3%
and 24% in the general population
• Young males, especially those predisposed to vagotonia,African Americans, and athletes are subpopulations known to have a higher prevalence of ERS
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ERS : Electrophysiologic Mechanism :
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ERS : ECG Diagnosis :
• The electrocardiographic hallmark of ERS is elevation (> 1 mm above baseline) of the QRS - ST junction
• Manifested as either QRS slurring or notching, ST segment elevation with upper concavity,
• ProminentT-waves in two or more contiguous inferior and/or lateral leads
Types :
• 1: ER in the lateral precordial leads that is • healthy male athletes and has the • lowest risk of malignant arrhythmias
• 2: ER in the inferior and inferolateral leads • greater risk of malignant arrhythmias;
• 3: ER pattern in all ECG leads • highest risk of malignant arrhythmias
and electrical storms.
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: ERS : Benign V/S Malignant :
Benign
• Rapidly ascending ST segment elevation) following J-point elevation
Malignant
• Horizontal or descending ST segment elevation
• Slurred or notched J-point elevation ≥ 2 mm
• ER pattern in inferior or inferolateral leads
• Persistent ER during exercise
• Extension of ER into a BrS pattern.
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ER : ECGs :
• Benign
• Malignant
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ER Pattern :
• 13 % of general population
• 75 % in Men
• Arrhythmia after 55 yrs • SCD 11/100000 with J waves
• 30/100000 with Horiz.ST elev.
• Due to ↓ Na/Ca current or↑ K current
• PMVT/Torsade
‘J’Wave syndromes:
• ERS
• Brugada Syndrome
• Osborne Waves
• Increased Vagal tone
• Neural Injury
• Hypercalcemia
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ARVD :
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LBBB, RBBB and LVH
• Discordance between the QRS complex and the ST-T abnormalities, • The ST segment and T wave are both abnormal and deviate in the same
direction, • The ST and T abnormalities are not dynamic. Exceptions : • Left ventricular hypertrophy may be associated with symmetric T-wave
inversion without ST-segment depression : HCM
Concordant = MI, Disconcordant = BBB but does not exclude MI
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PR/PQ Segment Depression : Pseudo ST Elev.
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Liu’s criteria for diagnosing atrial ischaemia / infarction : • PR elevation >0.5 mm in V5 & V6 with reciprocal PR depression in V1 &
V2
• PR elevation >0.5 mm in lead I with reciprocal PR depression in leads II & III
• PR depression >1.5 mm in the precordial leads
• PR depression >1.2 mm in leads I, II, & III
• Abnormal P wave morphology: M-shaped,W-shaped,irregular,or notched (minor criteria)
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Another Normal ECG : Pericarditis :
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Pericarditis • Diffuse pericarditis involves not only the subepicardial
layer of the ventricular wall, which is responsible for the ST-segment elevation, but also the subepicardial layer of the atrial wall, which causes an atrial injury pattern.
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ER V/s Pericarditis :
• The ratio of the T wave amplitude to the ST elevation should be > 4 if early repolarization is present. In other words, the T wave in early repolarization is usually 4 times the amplitude of the ST elevation. Another way to describe this would be that the ST elevation is less than 25% of the T wave amplitude in early repolarization.
• PQ Segment depression.
• The ST elevation in early repolarization resolves when the person exercises.
• Early repolarization, unlike pericarditis, should not be associated with any symptoms
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Hyperkalemia • Even though the pseudoinfarction pattern of
hyperkalemia is well known, the ST-segment elevation is so striking at times that one cannot help agonizing over
the possibility of coexistent acute infarction.
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Conclusions :
• All ST T abnormalities are not ischemic,
• Clinical data is a must for interpreting a given ECG,
• Comparing previous and subsequent ECGs very important,
• Know the metabolic milieu during the ECG recording,
• Remember channelopathies, specific Genetic syndromes.
Thank You