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ECG - Acute Coronary Syndrome

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Version Jan 2023

ECG And MI and Coronary Arteries

Site	Vessel occluded	ECG changes
Posterior:	Either RCA or Circumflex	Tall R waves and T wave V1-2. ST depression V1-V3
Anterior:	LAD	ST elevation V1-V6
Inferior:	II, III, avF	Either RCA or Circumflex. May be associated AV block or bradycardia
Anterolateral	Circumflex / LAD (Diagonal)
Anteroseptal	LAD	I, aVL, V1-V4

Criteria for diagnosing MI

New ST Elevation in two contiguous leads of > 1 mm in all leads other than V2/3
ST elevation in V2/3 of > 2 mm in men > 40, 2.5 mm in mean < 40, or 1.5 mm in women
New or presumed new LBBB
Isolated Posterior MI
Reciprocal changes help support diagnosis

Differentials of ST elevation

Acute ST Elevation MI
Early repolarisation where the ST looks elevated in V2, V3. There are no reciprocal changes elsewhere
Myopercarditis saddle-shaped ST-elevation all except cavity leads (aVr)
Coronary spasm - Prinzmetal's angina settles with antianginals
LV aneurysm - history of previous anterior MI. Diagnose on echo
Brugada syndrome - rare and not really associated with ACS.
Coronary artery spasm (Prinztmetal's angina)
During angioplasty
Takotsubo cardiomyopathy

Early Repolarisation - may be mistaken for Anteroseptal STEMI

A usually benign ECG pattern with an incidence of 5 to 13% of people so very common especially in young healthy athletes
ST elevation (J point elevation) of 1 mm or more in 2 or more contiguous leads (usually inferior or lateral or both)
ST morphology similar to pericarditis
No reciprocal changes and large symmetrical T waves
It probably has nothing to do with actual early repolarization

Inferior STEMI

ECG And MI and Coronary Arteries

Site	Vessel occluded	ECG changes
Posterior:	Either RCA or Circumflex	Tall R waves and T wave V1-2. ST depression V1-V3
Anterior:	LAD	ST elevation V1-V6
Inferior:	II, III, avF	Either RCA or Circumflex. May be associated AV block or bradycardia
Anterolateral	Circumflex / LAD (Diagonal)
Anteroseptal	LAD	I, aVL, V1-V4

Anterior STEMI

Inferior STEMI

Modified Sgarbossa Criteria

Use to help tell

Sgarbossa's Criteria for MI in Left Bundle Branch Block
1 lead with =1 mm of concordant ST elevation
1 lead of V1-V3 with = 1 mm of concordant ST depression
1 lead anywhere with = 1 mm STE and proportionally excessive discordant STE, as defined by = 25% of the depth of the preceding S-wave.

STEMI

1st Hyperacute T waves
2nd ST elevation with reciprocal ST depression
3rd T wave inversion
4th Loss of R wave height
5th Q waves develop: these signify transmural infarction which acts as an electrical window allowing the depolarisation of the opposite myocardium

NSTEMI

Widespread ST depression
ST-T changes
No changes

Ischaemia

ST depression
T wave changes
Deep Inverted T waves - can often indicate severe coronary artery disease in that territory e.g. Deep anterior T wave inversion - LAD stenosis and Deep inferior T wave inversion - suggests RCA stenosis

Correlating ECG and Culprit vessel- there is much variation.

Arterial occlusion ECG leads affected with ST elevation, T wave inversion, Q waves

Left anterior descending V1-V4

Circumflex V1 - reciprocal e.g. tall R wave instead of Q waves and ST depression rather than elevation (True posterior)

Right coronary artery ST elevation, T wave changes, Q waves in II, III, aVF (inferior)

Distal RCA/Side branch of Cx Lateral V5/6 changes (lateral)

Proximal LAD V1-6, I, aVL anterolateral

Proximal RCA II,III,avF, V5,V6 inferolateral

Proximal RCA/CX II,III,aVF dominant R wave in V1 (inferoposterior)

Proximal RCA/CX II,III,aVF dominant R wave in V1, V5,V6 (inferoposteriolateral)

Arterial occlusion	ECG leads affected with ST elevation, T wave inversion, Q waves
Left anterior descending	V1-V4
Circumflex	V1 - reciprocal e.g. tall R wave instead of Q waves and ST depression rather than elevation (True posterior)
Right coronary artery	ST elevation, T wave changes, Q waves in II, III, aVF (inferior)
Distal RCA/Side branch of Cx	Lateral V5/6 changes (lateral)
Proximal LAD	V1-6, I, aVL anterolateral
Proximal RCA	II,III,avF, V5,V6 inferolateral
Proximal RCA/CX	II,III,aVF dominant R wave in V1 (inferoposterior)
Proximal RCA/CX	II,III,aVF dominant R wave in V1, V5,V6 (inferoposteriolateral)

ECG References

See Excellent EKG resource

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