Electrocardiographic Diagnosis of Life-threatening

Acute Coronary Syndrome

(High-Risk ECG Pattern in ACS)

dr. Supartono, SpPD, K-KV, FINASIM

 Acute Coronary Syndrome
 The term acute coronary syndrome (ACS)
refers to any group of clinical symptoms
compatible with acute myocardial ischemia
and covers the spectrum of clinical
conditions ranging from unstable angina (UA)
to non- ST segmen elevation myocardial
infarction (NSTEMI) to ST segmen myocardial
infarction (STEMI)

 ACS are life threatening conditions that can punctuate the course of patients
with coronary artery disease at any time
 Symptoms which occur due to a partial or total blockage of a coronary artery
causing myocardial
• ischemia (cells starving of oxygen) OR
• infarction (cell death).

Amsterdam, E. A. et al. 2014 AHA/ACC Guideline for the management of patients with non-ST-elevation acute coronary syndromes:
A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. Circulation
ACS: Tip of the Atherothrombotic “Iceberg”
Acute Plaque Rupture ACS
(UA/NSTEMI/STEMI)‫‏‬

32 million heart attacks

and strokes per year
Clinical

Subclinical

Undetected billions are

at high cardiovascular
risk….
Due to hypertension,
diabetes, high lipids,
tobacco use, physical
inactivity and unhealthy
diet

ACS, acute coronary syndrome; UA, unstable angina; NSTEMI, non-ST-segment elevation myocardial
infarction; STEMI, ST-segment elevation myocardial infarction.
Adapted from Goldstein JA. J Am Coll Cardiol. 2002;39:1464-1467.
Initial Assessment Suspected ACS

ESC Guidelines for the management of Acute Coronary Syndrome in patients without persistent ST Elevation.
European Heart Journal 2011
Cardiac biomarkers in ST-elevation myocardial infarction

Alpert JS, et al. Myocardial infarction redefined: a consensus document of the Joint European Society of Cardiology/American
College of Cardiology Committee for the redefinition of myocardial infarction.
J Am Coll Cardiol 2000;36:959-69
Complication of Myocardial Infarction
The Role of ECG in ACS

2017 ESC Guidelines for the management of acute myocardial infarction in patients
presenting with ST-segment elevation. European Heart Journal (2017)
Coronary Anatomy
Coronary Anatomy
Electrical conductive system of the heart
The Lead System
 The Coronary Arteries
and Their Relation to ECG Leads

Clinical ECG Interpretation. ecgwaves.com

Unstable Angina/Non–ST Elevation Myocardial Infarction

Lily LS. Pathophysiology of Heart Disease. Wolter Kluwers 2016

 ECG evolution during STEMI

• ST elevation at the J point in two contiguous leads of >0.1 mV in all leads

other than leads V2-V3 – For leads V2-V3 the following cut points apply: ≥0.2
mV in men ≥40 years, ≥0.25 mV in men <40 years, or ≥0.15 mV in women
• Other conditions which are treated as a STEMI – New or presumed new LBBB
– Isolated posterior MI
• The presence of reciprocal ST depression helps confirm the diagnosis

Lily LS. Pathophysiology of Heart Disease. Wolter Kluwers 2016

ECG Criteria for Acute Myocardial Infarction
in Patients With Bundle Branch Block
Right Bundle Branch Block
Right Bundle Branch Block
How to spot myocardial infarction
in a patient with RBBB ?

Romulo FB. Basic and Bedside Electrocardiography. Wolter Kluwers 2009

RBBB Without Myocardial Infarction

RBBB With Myocardial Infarction

Left Bundle Branch Block
Left Bundle Branch Block
 Sgarbossa Criteria

The criteria used to diagnose infarction in patients with LBBB are:

• Concordant ST elevation > 1mm in leads with a positive QRS complex (score 5)
• Concordant ST depression > 1 mm in V1-V3 (score 3)
• Excessively discordant ST elevation > 5 mm in leads with a -ve QRS complex
(score 2)

These criteria are specific, but not sensitive for myocardial infarction. A total score
of ≥ 3 is reported to have a sensitivity 20% and specificity of 90% for diagnosing
myocardial infarction
 Modified Sgarbossa Criteria
• ≥ 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.
 Is this STEMI?
Patient with typical chest pain and elevated cardiac enzym

• LBBB
• Discordant ST segment elevation >5 mm in V2 - V3

Romulo FB. Basic and Bedside Electrocardiography. Wolter Kluwers 2009

• Concordant ST elevation in aVL ≥ 1 mm (= 5 points)
• Q wave in lead I and the concordant ST depression in the
inferior leads III and aVF  High lateral infarction
Right Ventricular Myocardial Infarction
• 25% to 50% of cases of inferior wall myocardial
infarction are associated with a right ventricular
myocardial infarction (RVMI)

• RVMI was associated with a 2.6-fold increased risk

of mortality as well as an increase in ventricular
arrhythmias, high-grade atrioventricular block, and
mechanical complications

• The hemodynamic syndrome associated with RVMI

includes hypotension, elevated venous pressures,
and shock without evidence of congestive heart
failure
How to spot right ventricular infarction ?
 The first step to spotting RV infarction is to suspect it… in all
patients with inferior STEMI!

 In patients presenting with inferior STEMI, right ventricular

infarction is suggested by the presence of:

 ST elevation in V1 – the only standard ECG lead that looks

directly at the right ventricle.
 ST elevation in lead III > lead II – because lead III is more
“rightward facing” than lead II and hence more sensitive
to the injury current produced by the right ventricle.
 Other useful tips for spotting RVMI:

 ST elevation in V1 > V2
 ST elevation in V1 + ST depression in V2 (= highly specific
for RV MI)
 Isoelectric ST segment in V1 with marked ST depression
in V2

 RVMI is confirmed by the presence of ST elevation in

the right-sided leads (V3R-V6R)
The Right Sided Leads
A 63-year-old man with chest discomfort, Dx ?

• ST elevation in lead III > II

• ST depression in leads I and aVL
• ST elevation in lead aVF > ST depression in lead V2
Right-sided precordial leads

ST-segment elevation in leads V3R-V6R  a right ventricular

myocardial infarction
Right Ventricular Myocardial Infarction. Perm J 2017;21:16-105
Posterior Myocardial
Infarction
• Posterior Myocardial Infarction  Necrosis of the part
of the left ventricle located beneath the
atrioventricular sulcus

• 15-20% of STEMIs, usually occurring in the context of an

inferior or lateral infarction

• Isolated posterior MI is less common (3-11% of infarcts)

• Posterior extension of an inferior or lateral infarct

implies a much larger area of myocardial damage 
increased risk of left ventricular dysfunction and death
How to spot posterior infarction ?
As the posterior myocardium is not directly visualised by the
standard 12-lead ECG, reciprocal changes of STEMI are sought in
the anteroseptal leads V1-3

Posterior MI is suggested by the following changes in V1-3:

• Horizontal ST depression
• Tall, broad R waves (>30ms)
• Upright T waves
• Dominant R wave (R/S ratio > 1) in V2

In patients presenting with ischaemic symptoms, horizontal ST

depression in the anteroseptal leads (V1-3) should raise the
suspicion of posterior MI
Electrocardiographic Criteria of Posterior
Myocardial Infarction
Standard 12-lead ECG :
• ST-segment depression (horizontal >>
downsloping/upsloping)*
• Prominent R wave*
• R/S wave ratio >1.0 in lead V2
• Prominent, upright T wave*
• Combination of horizontal ST-segment depression with
upright T wave*
• Co-existing acute inferior and/or lateral MI
Additional lead ECG (posterior leads V7 to V9) ≥ 1 mm ST-
segment elevation
* Limited to leads V1 to V3

Brady W, et al. Electrocardiographic manifestations acute posterior wall

myocardial infarction. J Emerg Med. 2001;20:391-401
Posterior leads

Leads V7-9 are placed on the

posterior chest wall in the
following positions :

• V7 – Left posterior axillary line,

in the same horizontal plane as
V6
• V8 – Tip of the left scapula, in
the same horizontal plane as V6
• V9 – Left paraspinal region, in
the same horizontal plane as V6
The mirror image of the “injured area”

Castellano Reyes C, et al. Clinical Electrocardiography. 2nd ed. Madrid: Elsevier; 2010
A 70-year-old woman with chest pain, dyspnoea and nausea.
Cardiac troponin-T 0.59 µg/l (N<0.04 µg/l)
Posterior leads V7 to V9
Coronary angiography
CAG showing a 90% stenosis of
the circumflex artery (white
arrow) and a 70% stenosis in the
left anterior descending (black
arrow) artery

E.O.F. van Gorselen, et al. Posterior myocardial infarction: the darkside of the moon
Netherlands Heart Journal, Volume 15, Number 1, January 2007
Patient with chest pain, Dx ?

• Horizontal ST depression in V1-3

• Dominant R wave (R/S ratio > 1) in V2
• Upright T waves in V2-3
Posterior leads V7 to V9

Life in The Fast Lane

Wellens Syndrome
Wellens Syndrome
• A pattern of deeply inverted or biphasic T waves in V2-3,
which is highly specific for a critical stenosis of the LAD
artery
• Results from a temporary obstruction of the LAD coronary
artery  Rupture of an atherosclerotic plaque leading to LAD
occlusion, with subsequent clot lysis
• Patients may be pain free by the time the ECG is taken and
have normally or minimally elevated cardiac enzymes  High
risk for extensive anterior wall MI within the next few days
to weeks
• Definitive treatment  Cardiac catheterization (PCI) to
relieve the occlusion
Diagnostic criteria for Wellens syndrome :
• Deeply inverted T waves in leads V2 and V3 (may also be
seen in leads V1, V4, V5, and V6) or biphasic T waves (with
initial positivity and terminal negativity) in V2 and V3
• Isoelectric or minimally elevated ST segment, less than 1 mm
(in other words, no signs of an acute anterior wall
myocardial infarction)
• Preservation of precordial R-wave progression and no
precordial Q waves (in other words, no signs of old anterior
wall infarct)
• Recent history of angina
• ECG pattern present in a pain-free state
• Normal or slightly elevated cardiac markers
Wellens syndrome

Illustration by Bryan Parker

A 33-year-old male, chest pain
ECG during pain-free interval, biphasic T-waves in lead V2, V3

ECG during angina , resolution of T-wave changes (Pseudo-normalization)

Coronary angiogram  Critical mid LAD stenosis

Wellens’ Syndrome, An Electrocardiographic Warning Sign.

https://www.researchgate.net/publication/313040188
Case :
• A 52-year-old male, history of chest pain accompanied by
shortness of breath
• Past medical history; hypertension (-), DM (-), smoking (+),
dyslipidemia (+)
• Cardiac troponin 137 ng / L (<2.0)
• LDL Cholesterol 163 mg / dL, Triglycerides 360 mg / dL
What is the diagnosis?
 Coronary Angiography

RCA LCA
 Coronary Angiography

LCA Pasca PCI

de Winter’s sign
• De Winter ECG pattern was reported as an indicator of acute
LAD coronary artery occlusion and is considered an anterior
ST-elevation myocardial infarction (STEMI equivalent)

• 2% of acute LAD occlusion

• de Winter postulated endocardial conduction delay of an

anatomical variant of Purkinje fibers

• The immediate recognition of these ECG changes is essential

for referring patients to urgent angiography and reperfusion
therapy to improve the clinical outcomes
Diagnostic Criteria

• Tall, prominent, symmetric T waves in the precordial leads

• Upsloping ST segment depression >1mm at the J-point in the
precordial leads
• Absence of ST elevation in the precordial leads
• ST segment elevation (0.5mm-1mm) in aVR
Accuracy of the de Winter’s sign

Positive predictive value (PPV) of de Winter’s sign

Research study PPV (95% confidence interval)

Sclarovsky et al., 1988 95.2% (76.2–99.9%)
Verouden et al., 2009 100% (69.2–100.0%)
Misumida et al., 2015 100% (51.7–100%)

Raja et al. Cardiac catheterization in de Winter’s sign.

Annals of Translational Medicine, Vol 7, No 17 September 2019
De Winter T waves
• Upsloping ST depression in the precordial leads (> 1mm at J-point)
• Peaked anterior T waves (V2-6), with the ascending limb of the T
wave commencing below the isoelectric baseline
• Subtle ST elevation in aVR > 0.5mm
 A 65-year-old man, sudden chest
pain at rest associated with
diaphoresis for 55 min
Cardiac troponin T 0.049 ng/mL
(normal value: 0.010–0.023)

Complete occlusion of the proximal

LAD and a 90% stenosis of the
middle of the LCx

Lin YY et al. Dynamic evolution of de Winter syndrome. World J Clin Cases 2019
 What Is the Affected Artery?
Where Is the Occlusion Located?
The concept of injury vector
 Algorithm for predicting infarct related artery
in inferior wall myocardial infarction

Elevation : LCx STE in Lead II> Lead III

Or STD V1-V3
If V4R absent, LCx
then look at Isoelectric
ST in Lead I STE in Lead III> Lead II
STE in Depression : RCA
II, III, aVF RCA
Lead V4R
present

Electrocardiographic localization of infarct related coronary artery

in acute ST elevation myocardial infarction. J Clin Sci Res 2013;2:151-60
 RCA atau LCx ?

• STE in L III> L II
• STE in L II, III, aVF > STD in V1-V3
 Coronary angiography
Before PCI After PCI

A Bay ´es de Luna, et al. The 12-Lead ECG in ST Elevation Myocardial Infarction,
a Practical Approach for Clinicians. India: Blackwell Publishing; 2007
The concept of injury vector
The concept of injury vector
 Electrocardiographic predictors of location of
occlusion in LAD in anterior myocardial infarction

D1=first diagonal, S1=first septal, LAD=left anterior descending coronary artery,

STD=ST segment depression, STE=ST segment elevation, RBBB=right bundle branch block.

Electrocardiographic localization of infarct related coronary artery in acute ST elevation myocardial infarction.
J Clin Sci Res 2013;2:151-60
The Algorithm to localize the site of LAD occlusion
in the case of STEMI

A Bay ´es de Luna, et al. The 12-Lead ECG in ST Elevation Myocardial Infarction,
a Practical Approach for Clinicians. India: Blackwell Publishing; 2007
A 55-year-old woman, chest pain for >2 hours, hypertension (+),
high cholesterol (+)

What is the occlusion located ?

• STE  V1-V3
• STD  II, III, aVF Occlusion prox to D-1
• STD (Lead III + aVF) ≥ 2,5 mm
 Coronary angiography

Before PCI After PCI

Miguel Fiol-Sala. Acute Coronary Syndrome. Circulation. 2017;136:691–693

 Left Main Coronary Disease
 Typical ECG findings with LMCA occlusion :
• Widespread horizontal ST depression, most
prominent in leads I, II and V4-6
• ST elevation in aVR ≥ 1mm
• ST elevation in aVR ≥ V1

 ST elevation in aVR is not entirely specific to LMCA

occlusion
 ST Elevation in aVR may also be seen with:
• Proximal LAD occlusion
• Severe triple-vessel disease (3VD)
• Diffuse subendocardial ischaemia
Case :

• A 54 -years -old male, typical chest pain, shortness

of breath, history of hypertension (+), diabetes (-),
smoking (+), dyslipidemia (+)
• Cardiac troponin 9.4 ng / L (<2.0)
What Is the Affected Artery?
 Coronary Angiography

RCA LCA
 Coronary Angiography

LCA LCA
Thank you
Clinical ECG Interpretation. ecgwaves.com
Morphology of the Elevated ST segment
ST Segment Morphology in Other Conditions
ST Segment Depression
J point in a) normal; b) c) J point elevation; d) J point depression; e)
with J wave (Osborn wave)
Summary of ECG Features of RVMI Complicating Inferior MI

Kakouros N, Cokkinos DV. Right ventricular myocardial infarction:

pathophysiology, diagnosis, and managementPostgrad Med J 2010;86:719e728.
The algorithm to
locate the zone of
LAD occlusion in case
of ACS with
predominant ST-
segment elevation in
precordial leads
The algorithm to
identify which is the
occluded artery (RCA vs
LCX) in case of ACS with
predominant ST-
segment elevation in
inferior leads