Causes of ST Segment Elevation - Differential Diagnosis Framework STEMI: • Upsloping convex STE: "Pardee's sign" + PPD • Opposing leads ST depression Pericarditis/Myocarditis: • Diffuse ST-segment elevation (concave morphology) • Reciprocal ST-segment depression in aVR, not in aVL • PR-segment depression Takotsubo Cardiomyopathy: • STE mainly in anteroseptal leads (V2-V4) • These disappear in a few days and are replaced by T wave inversion and a prolonged QT interval J Wave Syndromes • Early Repolarization: - Early-repolarization pattern, with a notch at the J point in V4 - The ST segment is concave, and the T waves are relatively tall - Reciprocal ST depression in aVR, not in aVL, when limb leads are involved • Brugada Syndrome: - rSR' in V1 and V2 - ST-segment elevation in V1 and V2 typically downsloping - Coving ST Secondary Repolarization Abnormalities • Left Bundle Branch Block: - QRS duration > 120ms - Dominant S wave in V1 - Broad monophasic R wave in lateral leads (I, aVL, V5-6) - Absence of Q waves in lateral leads - Prolonged R wave peak time > 60ms in leads V5-6 • Left Ventricular Hypertrophy: - Concave ST elevation with prominent T waves • Ventricular Pacing: - Pacing spike precedes the QRS complex - Right ventricle pacing lead placement results in a QRS morphology similar to LBBB - ST segments and T waves should be discordant with the QRS complex Pulmonary Embolism: • T-wave inversion in the right precordial leads • ST-segment elevation, or both in the anteroseptal and inferior leads • S1Q3T3 pattern; complete or in-complete right bundle-branch block; and sinus tachycardia Electrolyte Disorders: • Hyperkalemia: - ST-segment elevation - Widened QRS complexes; tall, pointed, tented T waves (Eiffel Tower sign) and low-amplitude or no P waves • Hypercalcemia: - J wave/Osborne waves - Short QT LV Aneurysm: • ST elevation seen > 2 weeks following an acute myocardial infarction • Seen in the precordial leads • May exhibit concave or convex morphology Prinzmetal's Angina: • Epicardial artery is episodically "pinched off" as a result of spasm, the ST segment becomes elevated in the leads facing the affected area ST Elevation of Normal Variant: • Seen in V3 through V5 with inverted T waves • Short QT, high QRS voltage Other Causes - STE can be seen in: • Hypothermia (Osborn waves) • Intracranial pathologies: (Cerebral T waves) Deep T-wave inversions (especially in subarachnoid or intraparenchymal hemorrhage) • Wolff-Parkinson-White syndrome • Post-cardioversion • Acute aortic dissection • Sodium-channel blocking drugs #STElevation #ST #STEMI #Segment #Elevation #differential #diagnosis #cardiology #ecg #ekg #electrocardiogram
