Posterolateral MI
Dressler - de Winter sign
aVR sign
Wellens sign, Wellens syndrome
- Acute thrombotic LCX occlusion – it is a STEMI
- Diagnostic criteria
- presentation with acute chest pain
- ST depression in the anterior chest leads which may be due to anterior ischemia, posterior STEMI or RVH with strain
- posterior STEMI is frequently accompanied by subtle Q waves, subtle ST elevation or the “wishbone sign” in the inferior and/or lateral leads
- It is a STEMI but ST elevation may not be seen in the 12-lead ECG (“STEMI without STE”)
- Place ECG leads to the back (V7-V8-V9)
- Any ST elevation in the posterior leads warrants immediate cath/reperfusion
Dressler - de Winter sign
- Acute thrombotic proximal LAD occlusion – a STEMI equivalent
- in 98% of cases of acute LAD occlusion: there is frank electrocardiographic STEMI
- in 2% of cases of acute LAD occlusion: Dressler - de Winter sign
- Diagnostic criteria
- presentation with acute chest pain
- very tall “hyperacute” T waves in the chest leads
- usually accompanied by upsloping ST depression (ST depressed at the J point)
- patients are frequently young males
- chest pain to the “de Winter” ECG presentation is usually within 30-120 minutes
- Imminent risk of extensive anterior STEMI
- The de Winter sign warrants immediate cath/reperfusion
aVR sign
- 80% specific for tight left main coronary artery stenosis – high risk of large STEMI
- Diagnostic criteria
- presentation with acute chest pain
- diffuse ST-segment depression
- ST elevation ³1 mm in aVR
- High but not necessarily imminent risk of STEMI, usually extensive, frequently lethal (“widow-maker artery”)
- Urgent cath/reperfusion is indicated (but not necessarily immediate cath)
Wellens sign, Wellens syndrome
- Suggestive of tight proximal LAD stenosis – high risk of subsequent anterior STEMI
- Diagnostic criteria
- presentation with chest pain
- biphasic (positive-negative) T waves in the anterior chest leads (type A – 25%) and/or
- deep symmetrical negative T waves in the chest leads (type B – 75%)
- no abnormal Q waves; normal R-wave progression in the chest leads
- T-wave abnormalities can be present even in the pain-free state
- no or only subtle troponin elevation
- If undetected/untreated, high risk of subsequent STEMI, usually days/weeks later
- In typical Wellens syndrome: cardiac cath without prior stress testing is indicated