Unstable angina non ST elevation myocardial infarction electrocardiogram: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
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| [[File:Siren.gif|30px|link=Unstable angina/ NSTEMI resident survival guide]]|| <br> || <br> | |||
| [[Unstable angina/ NSTEMI resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] | |||
|} | |||
{{Unstable angina / NSTEMI}} | {{Unstable angina / NSTEMI}} | ||
{{CMG}}; '''Associate Editors-In-Chief:''' {{CZ}}; [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S. | {{CMG}}; '''Associate Editors-In-Chief:''' {{CZ}}; [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S.; {{RT}} | ||
==Overview== | ==Overview== | ||
The EKG in patients with unstable angina can | 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 wave]]s, [[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 | ==Electrocardiogram in Unstable Angina/NSTEMI== | ||
The resting [[electrocardiogram]] in the patient with unstable angina / non-ST elevation MI may show any of the following: | The resting [[electrocardiogram]] in the patient with unstable angina / non-ST elevation MI may show any of the following: | ||
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* [[Non specific ST / T wave changes]] | * [[Non specific ST / T wave changes]] | ||
* Flipped or [[inverted T wave]]s | * Flipped or [[inverted T wave]]s | ||
* [[ST depression]] as shown below. ST depression carries the poorest prognosis. Greater magnitudes of | * [[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.<ref>{{cite journal | last = Tandy | first = TK |coauthors = Bottomy DP, Lewis JG | title = Wellens' syndrome | journal = Annals of Emergency Medicine | volume = 33 | issue = 3 | pages = 347–351 | year = 1999 | month = March | pmid = 10036351 | doi = 10.1016/S0196-0644(99)70373-2}}</ref> | |||
==EKG Examples== | ==EKG Examples== | ||
Shown below is an EKG from a patient with unstable angina. [[ST depression]] in [[Electrocardiogram#Precordial|V2]], [[Electrocardiogram#Precordial|V3]],[[Electrocardiogram#Precordial|V4]] and [[Electrocardiogram#Precordial|V6]] can be noted | Shown below is an EKG from a patient with unstable angina. [[ST depression]] in [[Electrocardiogram#Precordial|V2]], [[Electrocardiogram#Precordial|V3]], [[Electrocardiogram#Precordial|V4]] and [[Electrocardiogram#Precordial|V6]] can be noted: | ||
[[Image:unstable-angina.jpg|center|500px]] | [[Image:unstable-angina.jpg|center|500px]] | ||
Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/Main_Page | ''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) <ref name=Guidelines> 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) </ref>== | ||
{{ | |||
===Early Risk Stratification=== | |||
{|class="wikitable" | |||
|- | |||
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | |||
|- | |||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | |||
|- | |||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' If the initial [[ECG]] is not diagnostic but the patient remains symptomatic and there is a high clinical suspicion for [[ACS]], serial [[ECG]]s (e.g., 15- to 30-minute intervals during the first hour) should be performed to detect ischemic changes. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | |||
|} | |||
{|class="wikitable" | |||
|- | |||
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]] | |||
|- | |||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | |||
|- | |||
|} | |||
{|class="wikitable" | |||
|- | |||
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]] | |||
|- | |||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | |||
|- | |||
|} | |||
[[ | ===Immediate Management=== | ||
[[ | ====Discharge From the ED or Chest Pain Unit==== | ||
[[ | {|class="wikitable" | ||
|- | |||
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]] | |||
|- | |||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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 [[ECG]]s and [[cardiac troponin]] at 3- to 6-hour intervals. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | |||
|- | |||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki> | |||
|} | |||
==References== | |||
{{Reflist|2}} | |||
{{WH}} | {{WH}} | ||
{{WS}} | {{WS}} | ||
[[Category:Ischemic heart diseases]] | |||
[[Category:Intensive care medicine]] | |||
[[Category:Disease]] | |||
[[Category:Cardiology]] | |||
[[Category:Emergency medicine]] | |||
[[Category:Mature chapter]] | |||
[[Category:Up-To-Date]] | |||
[[Category:Up-To-Date cardiology]] | |||
[[Category:Best pages]] | |||
Latest revision as of 21:09, 5 December 2022
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Risk Stratification Before Discharge for Patients With an Ischemia-Guided Strategy of NSTE-ACS |
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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:
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
- ↑ 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) - ↑ 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)