Unstable angina / non ST elevation myocardial infarction electrocardiogram

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.; Raviteja Guddeti, M.B.B.S. [3]

Overview

The EKG in patients with unstable angina can vary. In some cases, no changes on EKG will be appreciated. In other cases, a resting EKG may show flipped or inverted T waves, ST segment depression, or non-specific ST-T changes. It is the first line of assessment in any patient suspected of having unstable angina.

Electrocardiogram in Unstable Angina/NSTEMI

The resting electrocardiogram in the patient with unstable angina / non-ST elevation MI may show any of the following:

  • No changes
  • Non specific ST / T wave changes
  • Flipped or inverted T waves
  • ST depression as shown below. ST depression carries the poorest prognosis. Greater magnitudes of down sloping ST depression are associated with a high in-hospital, 30-day and 1-year mortality. 1 year MI or death rate in patients with new ST deviation (more than 1 mm from baseline) has been shown to be 11% compared to 6.8% in patients with isolated T-wave inversion.

Wellens' syndrome is an electrocardiographic manifestation of critical proximal left anterior descending (LAD) coronary artery stenosis in patients with unstable angina. It is characterized by symmetrical, often deep >2mm, T wave inversions in the anterior precordial leads. A less common variant is biphasic T wave inversions in the same leads.[1]

EKG Examples

Shown below is an EKG from a patient with unstable angina. ST depression in V2, V3, V4 and V6 can be noted:

Unstable-angina.jpg

Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page


2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes (DO NOT EDIT) [2]

Early Risk Stratification

Class I
"1. In patients with chest pain or other symptoms suggestive of ACS, a 12-lead ECG should be performed and evaluated for ischemic changes within 10 minutes of the patient’s arrival at an emergency facility. (Level of Evidence: C)"
"2. If the initial ECG is not diagnostic but the patient remains symptomatic and there is a high clinical suspicion for ACS, serial ECGs (e.g., 15- to 30-minute intervals during the first hour) should be performed to detect ischemic changes. (Level of Evidence: C)"
Class IIa
"1. It is reasonable to obtain supplemental electrocardiographic leads V7 to V9 in patients whose initial ECG is nondiagnostic and who are at intermediate/high risk of ACS. (Level of Evidence: B)"
Class IIb
"1. Continuous monitoring with 12-lead ECG may be a reasonable alternative in patients whose initial ECG is nondiagnostic and who are at intermediate/high risk of ACS. (Level of Evidence: B)"

Immediate Management

Discharge From the ED or Chest Pain Unit

Class IIa
"1. It is reasonable to observe patients with symptoms consistent with ACS without objective evidence of myocardial ischemia (nonischemic initial ECG and normal cardiac troponin) in a chest pain unit or telemetry unit with serial ECGs and cardiac troponin at 3- to 6-hour intervals. (Level of Evidence: B)"
"2. It is reasonable for patients with possible ACS who have normal serial ECGs and cardiac troponins to have a treadmill ECG before discharge or within 72 hours after discharge. (Level of Evidence: A)"

References

  1. Tandy, TK (1999). "Wellens' syndrome". Annals of Emergency Medicine. 33 (3): 347–351. doi:10.1016/S0196-0644(99)70373-2. PMID 10036351. Unknown parameter |month= ignored (help); Unknown parameter |coauthors= ignored (help)
  2. Ezra A. Amsterdam, MD, FACC; Nanette K. Wenger, MD 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. JACC. September 2014 (ahead of print)

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