VA morning report 7.11.17: ST elevations!

Case Summary
Thanks to Tyler for presenting an interesting case of 81M with CV risk factors who p/w chest pain with found to have sub-millimeter ST elevations and marked troponin elevation due to ACS versus hypertensive emergency – cath pending!

Top Pearls
1. We use a combination of the history, EKG and troponin to help diagnose ACS. Scoring systems usually rely on at least two of three being positive, but atypical presentations with a marked derangement in only one of the three parameters do occur.
2. The differential diagnosis of ST elevations includes acutely life threatening causes, but less severe diagnoses are possible – see below.
3. Prior EKGs are extremely helpful in the assessment of acute chest pain. Look for evidence of ischemia (Q waves), cardiomyopathy (LVH) or conduction system disease (LBBB)

ST elevation
  • > 1mm STE in 2 contiguous leads as measured from the J point.
  • Except in V2-V3
    • > 2mm in men
    • > 1.5 mm in women

CausesST elevations

Owing to the morbidity and need for urgent treatment, STEMI is the default diagnosis is patients with ST elevations in contiguous leads.
However, there are features of the EKG that can point to an alternate diagnosis:


Prior EKGs

Prior EKG’s can have very important clues to the current presentation. Assess for the prior EKG for:

  • Old ischemia
    • Q waves
    • Poor R wave progression (anterolateral MI)
    • Persistent ST elevation  (aneurysm)
  • Cardiomyopathy
    • Non-specific T wave changes
    • LVH
    • Low voltages
  • Other
    • Axis shift (right axis shift from lateral MI)
    • Conduction system disease (LBBB)




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