ECG interpretation: NSTEMI

Primary PCI and direct admission of high

risk NSTEMI

Ron Lilly SAS

Joanne Simpson GJNH
Wednesday 17th February 2016
 Aims

Recognise the ECG patterns which occur in NSTEMI

Focus on those which occur most commonly

Difficult ECG scenarios

NSTEMI definition
ST elevation myocardial infarction (STEMI)

acute chest pain and persistent ST elevation

generally reflects an acute total coronary occlusion

immediate reperfusion by primary angioplasty

Non ST elevation myocardial infarction (NSTEMI)

acute chest pain with or without ECG changes

partial occlusion of a coronary artery

 NSTEMI definition
Presentation Ischemic Discomfort

ACS

Working Dx

ECG No ST Elevation ST Elevation

NSTE-ACS

Cardiac Biomarker UA NSTEMI * STEMI *

Unstable Angina Myocardial Infarction Noncardiac

Final Dx NQMI QwMI Etiologies
Assessment of a patient with
suspected ACS
 NSTEMI: considerations
Clinical spectrum

Symptom Ongoing Haemodynamic Cardiac

free ischaemia instability arrest

Ongoing pain
Marked ST depression
Heart failure
Electrical or haemodynamic
instability
 NSTEMI: ECG changes

persistent or transient ST-segment depression

T-wave inversion

flat T waves or pseudo-normalization of T waves

normal ECG
1. What does this ECG show?
 1. What does this ECG show?

1. T wave flattening inferiorly

2. Normal ECG

3. T wave inversion

4. ST depression
ST depression
2. What does this ECG show?
 2. What does this ECG show?

1. Normal ECG

2. T wave inversion

3. ST elevation

4. ST depression
3. What does this ECG show?
 3. What does this ECG show?

1. Normal ECG

2. T wave inversion

3. ST elevation

4. ST depression
Pre-hospital ECG
 Wellens syndrome

T waves: deeply inverted or biphasic

Critical stenosis of left anterior descending artery

Patients are high risk

 Difficult ECGs

Mimics are common

Aim remains not to miss STEMI or high risk NSTEMI

Low threshold for discussion

1. What does this ECG show?
 1. What does this ECG show?

ST elevation anteriorly

ST depression

Left bundle branch block

Long QT interval
2. What does this ECG show?
 2. What does this ECG show?

Left ventricular hypertrophy

Anterior ST elevation

ST depression

Normal ECG
3. What does this ECG show?
 3. What does this ECG show?

ST depression

Anterior ST elevation

Left ventricular hypertrophy

Broad QRS complex

 Electrolyte abnormality

Potassium, sodium, calcium and magnesium all

essential for normal electrical activity of heart

Characteristic ECG changes but many are non

specific

Consider in:

- underlying kidney disease

- vomiting, diarrhoea and dehydration

 Summary

The clinical presentation is paramount

ECG changes in combination with positive troponin

highly suggestive of NSTEMI

Be aware of mimics
Extra ECGs if have time
ST depression
ST depression
T wave inversion
Wellens syndrome
Wellens syndrome
Right bundle branch block