I. STEMI without STE
II. de Winter sign
III. aVR sign
IV. Wellens sign
- Discussed last month
- ST depression in anterior chest leads: consider posterolateral STEMI – electrodes to the back
- Subtle ST elevation in I, aVL, V2, ST depression in III (“South African flag sign”): consider high lateral STEMI – place V4-V5-V6 1 and 2 interspaces higher
- Subtle ST elevation in the inferior leads with ST elevation in V1 but not in V2: probable RV MI – obtain right-sided chest leads
- Medical emergency; door-to-balloon time < 90 min
II. de Winter sign
- Usually in young males who present with severe chest pain
- Always in the chest leads
- J-point depression followed by upsloping ST segments followed by tall “hyperacute” T waves
- Usually signifies subtotal or total occlusion of proximal LAD
- Medical emergency; immediate cath
III. aVR sign
- Presentation with acute chest pain (ACS)
- Diffuse ischemic ST depression
- ST elevation in aVR ≥ 1 mm
- ST elevation in aVR usually higher than ST elevation in V1
- 80% specific for left main or left main equivalent coronary artery obstruction
- High risk of acute MI and cardiogenic shock, death
- Urgent cath indicated (probably within hours)
IV. Wellens sign
- Presentation with acute chest pain (ACS)
- Deep symmetrical T-wave inversion in the anterior chest leads, or
- Biphasic (positive-negative) T waves in the anterior chest leads
- Suggests tight proximal LAD occlusion
- High mortality without cardiac cath, PCI
- Most patients should undergo cardiac catheterization
- Degree of urgency is uncertain