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Dr Smith’s ECG Blog

58 year old man, intermittent chest pain for 2 weeks

Pain settled spontaneously. Serial Troponins negative

ST elevation Vs early repolarisation• Benign early repolarisation– Widespread concave ST elevation ST – Most commonly V2 – V5– Notching is common at J point– Rare > 50 years– ST elevation is usually less than 2mm in precordial

leads, but can be more – < 0.5mm in limb leads– No reciprical ST segment changes– Normal R wave progression– Changes are relatively stable

Repeat ECG 12 hours later!!!

How good is it?• Retrospective review • Subtle anterior STEMI admitted to cardiology with

proven LAD occlusion Vs ED coded non cardiac chest pain with BER

• Mathematical formula comparing:– Height of ST elevation– QTc interval– R wave progression

• Actual calculation– (1.196 x ST-segment elevation 60 ms after the J point in

lead V3 in mm) + (0.059 x QTc in ms) - (0.326 x R-wave amplitude in lead V4 in mm)

Seems Complicated?

• The greater the ST elevation more likely to be STEMI

• The longer the QTC more likely to be STEMI • Poor R wave progression (small R wave in V4)

more likely to be a STEMI– A value of >23.4 was found to predict STEMI– </= 23.4 predicted early repolarization

• Sensitivity 86% • Specificity 91%

Learning Points• Significant LAD occlusion with dynamic ECG changes can still have

negative high sensitivity troponins• Don’t wait 12 hours for repeat ECG if any concerns• Try to learn some features that suggest BEP:

– Widespread concave ST elevation ST – Most commonly V2 – V5– Notching is common at J point– Rare > 50 years– ST elevation is usually:

• less than 2mm in precordial leads (but can be more!) • < 0.5mm in limb leads

– No reciprical ST segment changes– Normal R wave progression– Changes are relatively stable

• Download SubtleSTEMI and give it a try

PESIT TRIAL

PESIT

• Cross sectional multi-centre study• All patients with 1st episode syncope admitted

from ED• All then got D dimer testing and Wells score• Negative D dimer and PE unlikey wells score

testing stopped• +ve D dimer or PE likely Wells score CTPA

or Ventilation Perfusion Scan

PESIT

• 2584 patients presented to ED with syncope• 717 (27.7%) patients admitted• Of these 157 excluded• 560 patients included in study• > 75% over 70 years old• 58.9% had PE ruled out on Well’s score / D

dimer• 17.3% had diagnosed PE

Clot Burden

– 41.7% Main Pulmonary artery– 25% Lobar Artery– 26.4% Segmental Artery– 6.9% Subsegmental Artery

Discussion

Discussion• 1/6 pick up rate of PE for syncope sounds high• Remember that lots of people were sent home – so actually < 4% of

patients presenting with syncope to ED• PE was much more likely if:

– Tachopnoea– Tachycardiac– Hypotensive– Clinical signs of DVT– Active cancer

• You would hope we would expect PE in syncope ?cause if any of these features

• Did finding the PE also find the cause of syncope?– 26% segmental, 7% subsegemental– Much debate about the relevance of diagnosing these

• False +ve rate high • clinical significance of diagnosis uncertain

References• http://hqmeded-ecg.blogspot.com.au/2017/02/chest-

pain-st-elevation-and-negative.html• http://lifeinthefastlane.com/ecg-library/benign-early-

repolarisation/• http://www.emdocs.net/ber-vs-anterior-stemi/• http://www.annemergmed.com/article/S0196-

0644(12)00160-6/pdf• http://heart.bmj.com/content/94/12/1620.full• http://sinaiem.org/clot-or-not-what-are-we-going-to-

do-about-pesit/