Download Chest pain and syncope key slides

Chest Pain and syncope
Dr Cynthia Lim, Dr Peter Jordan, Dr
Megan Robb
ACS - STEMI
• If there is ST elevation, it will be a STEMI if:
• Any ST dep except V1 or aVR (allowed in acute
pericarditis)
• ST elevation III > II
• Horizontal or convex up ST elevation
• New Q waves
ACS - Pericarditis
• If ST elevation, pericarditis is more likely if:
• PR depression multiple leads
– Only reliably seen viral
– transient
• Low voltage and tachycardia = large
pericardial effusion
• Use T-P as baseline (not P-P interval)
• If in doubt serial ECGs, seek opinion
Normal variant ST elevation
• ST elevation may occur
as a normal variant and
represents EARLY
REPOLARISATION
• Seen in young adults
and people of African
descent
• ST elevation may also
indicate other
pathology
BENIGN features
•Concave up morphology
• Large symmetrical T-waves
• Notch at R and S wave
• J-point elevation (point at
where the ST segment begins.)
Pick the problem…
(What’s it called?)
Wellen’s Syndrome: Deep T-wave inversion or biphasic T-waves
in the absence of pain in V2 – V5.
Wellen’s Syndrome
• Pattern of ECG T-wave
changes which is associated
with critical proximal LAD
stenosis
• Presence may predict
proximal LAD occlusion
• Found in patients with
recent history of chest pain
but changes present in
absence of pain
• EST may be fatal
• Strong indicator for AG
30 yr old male with syncope
Brugada Syndrome
Brugada Syndrome
• ECG Findings
– Three types
– ST elevation v1 – v3 >
2mm
– Complete or incomplete
RBBB
• T-wave α types
– 1. Inverted
– 2. Biphasic
– 3. Upright
Brugada – Why do we care?
• Predisposition to polymorphic ventricular tachycardia
• Identification and treatment with AICD may prevent a young sudden cardiac death
25 year old with syncope on exercising
Arrthymogenic RV cardiomyopathy/dysplasia - inverted T waves in leads V1
through V5. Arrowheads point to late RV activation, called an epsilon wave
When to refer cardiac syncope to ED
• All 2nd degree and 3rd degree heart blocks
• All trifascicular blocks
• All rapid AF >120
• All SVTs in not terminated by Valsalva manouvre
• “funny looking” ST/T segments – discuss/fax
• Asymptomatic patients with WPW, ST changes can be referred to
cardiology OPA