EKG

MASTERY
ISCHEMIA

BY MEDGEEKS
What to think about?
Remember, if you are concerned about ischemia in a patient get
an EKG, and then repeat another EKG.

Ischemia is the only disease pathology that will cause changes to

occur in the EKG within minutes. Left ventricular hypertrophy,
conduction disturbances, bundle branch blocks, or cardiomyopathy
does not change this rapidly.

Geography
Which leads show what part of the coronary distribution:

Lateral: I, aVL, V5, V6 (Diagonal off of LAD or obtuse marginal off

of circumflex).

Inferior: II, III, aVF (often RCA; occasionally circumflex).

Anterior/Septal: V1, V2, V3, V4 (LAD).

True posterior: V1, V2 (Circumflex)

Remember mirror image opposites; new R wave instead of Q
waves and ST segment depression instead of elevation.

aVR: Speculation about left main, but not proven.

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Timing
Look for progression of ischemia, the longer the occlusion is
present, the more cell death.

Progression changes from T waves changes -> ST segment

changes -> Q waves.

T waves changes: Recent ischemia, cells injured, but recoverable.

In an MI, “T waves come first and leave last”. (Ischemia).

ST segment: Significant damage, cells are hanging on by a thread,

but still recoverable. More persistent ischemia than when T wave
changes are present. (Injury).

Q waves: Area of total cell death, permanent change. No more

electrical activity in that area. (Infarction).

Age of an MI
Acute MI: If Q waves are still forming, ST segments are still
elevated, and reciprocal ST depression is seen in opposite leads.

Recent MI: Q waves are formed, ST segments are no longer

elevated, but T wave inversions are still present.

Old or Indeterminant: Q waves are present, ST segments are no

longer elevated, no T wave inversion, only non-specific T wave
changes.
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T waves
If ischemia is present T waves can change over a period of
minutes; however, T waves changes alone do not always indicate
ischemia or infarction.

Can be related to bundle branch blocks, LVH, RVH,

cardiomyopathy, CNS bleeds, hyperkalemia, pacing, PVC, SVT,
ventricular tachycardia, and anything that can cause abnormal
repolarization.

ST Segment Elevation
Look at the height of the J point and compare this to an “electrically
silent area” such as PR interval. Also look at the shape of the ST
segment; curved upwards (frown shaped) or curved downward
(smile shaped) to tell difference between ischemia (“frown”) and
pericarditis (“smile”).

If ST segments are changing, this is no longer just ischemia, but at

least some cell injury (corresponding to elevated cardiac
enzymes); however, still possible reversible. If ST segments
remain present after MI is long over, think LV aneurysm.

Always look for reciprocal ST segment changes (R wave instead of

Q waves and ST segment depression instead of elevation); acute
MI have them, pericarditis does not.

Remember other heart disease, prolonged QTi, hyperkalemia,

hyperventilation, pancreatitis, stress, CNS changes can all lead to
ST segment elevation as well.
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 Pericarditis (How is this different
from acute ischemia?)
ST elevation first in pericarditis and T wave inversion second
(opposite in ischemia).

Majority of leads show ST elevation as opposed to geographic

leads in ischemia.

No reciprocal changes (biggest difference).

No Q waves.

ST elevation “smile”.

Low voltage if pericardial effusion is present.

Electrical alternans if pericardial effusion is present.

ST Segment Depression
Can be due to ischemia, but not necessarily permanent or
progressive.

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 Q waves
Represent extensive cardiac cell death.

ST segments are usually back to baseline by the time that

pathologic Q waves present.

If pathologic, it is more than 0.04s wide (one small box) and/or its
depth is more than 2mm or more depth than 1/3 the height of the R
wave in that lead.

Will likely be in contiguous geographic lead if its due to MI

Remember, about 25% of inferior Mis with lose their Q waves over
time.

Things that may mimic infarction on

EKG
WPW, HOCM, LVH or RVH, LAH, COPD, amyloid heart, chest
deformity (pectus excavatum), acute PE, myocarditis, myocardial
tumors, hyperkalemia, lead reversal, corrected transposition,
dextrocardia, LBBB, pancreatitis, muscular dystrophy, MV
prolapse, and pneumothorax.