ECG DIFFERENTIALS

**ST ELEVATION - AMI (15%) - BER (12%) - LVH (most common, 25%); fixed STE - LBBB (2nd most likely, 15%) - VPR - HyperK - Pericarditis/myocarditis - LV aneurysm (Fixed STE, appears weeks post MI, freq. anterior) - hypothermia - Brugada syndrome **SGARBOSSA CRITERIA FOR AMI 1) in LBBB (point value per lead) - STE >1mm concordant with QRS (5) - STE >5mm discordant with QRS (2) - STD>1mm in V1-V3 (3) => total >3 points suggests AMI => derived from GUSTO-1 substudy, 131 pts., poorly validated .**poorly validated when read by EPs (Annals Dec 2000) 2) in VPR - STE discordant >5mm - STE concordant >1mm - STD in V1-V3 >1mm => no point value, 17 pts. GUSTO-1, ?validation **ST DEPRESSION - hypoK - CAD - RVH/strain - digoxin effect (scooped) - CNS insults - MVP - Pericarditis - Cardiomyopathy - Spont. pneumothorax - LVH - Stokes-Adams syncope - LBBB/VPR - Persistent juvenile patterns **LAD - NOT LVH - LAFB (with qR in aVL) most common - Inf AMI - accessory pathway - COPD - VTach **RAD - RVH - Ant AMI - accessory pathway - LPFB (least common) **T WAVE INVERSION - ACS - LVH - PE - CVA - myocarditis - pericarditis stg. III - common Wellens syndrome - myxedema (flat/flipped) **PEAKED/PROMINENT T WAVES - early AMI - hyperkalemia - pericarditis - persistent juvenile pattern - HOCM - SAH - acute hemopericardium - LVH - BER **QTc PROLONGATION Congenital - Romano Ward (auto dom) - Jervell-Lange-Nielsen (auto rec., cong. deafness) Acquired - hypoMg - hypoCa - hypoK - terfenadine - azole Abx - liquid protein diets - new generation FQ's - macrolides ETM, clarithro - class Ia, III antidysrhythmics - inhalation anesthetics - cisapride - droperidol - TCA's, thioridazine, haldol, risperidone, phenothiazines - organophosphates - ionic contrast media - ?citalopram (Celexa) - myxedema coma - rheumatic fever **QT SHORTENING - digitalis - hyperCa - hyperK **LOW VOLTAGE SIGNALS - COPD - pericardial effusion - acute CHF - myxedema - amyloidosis - anasarca - obesity - low lead gain

**TALL R IN V1 - RBBB - acute PE/increased RVEDP - posterior AMI - RVH - WPW type A - HOCM - Duchenne MD - normal variant **PR PROLONGATION - AV conduction block - hypothermia - hyperthyroidism - normal variant - rheumatic fever - K disturbance (hyper/hypo) - degenerative dz. (Lev's, Lenegre) - infiltrative dz. (amyloid) - Lyme carditis ** PR SHORTENING - pericarditis - accessory pathway (WPW, LGL) - normal variant - catecholamine excess (pheo) - glycogen storage dz.

- ST/T wave ratio >0.25 (DDx BER); ST height = PR baseline to ST start (mm) T wave height = J point to T wave peak (mm) - low voltage QRS a/o alternans if effusion - stages I-III over hours/days - stage IV over weeks LVH (criteria if pt. > 35yo) - R in aVL >12mm - S in aVR >1.5mm - R in V6 > R in V5 - deep S wave in V1-V3 (>20mm) - sum S in V1 + R in V5 >35mm - sum R in limb I + S limb III >26mm - strain pattern in precordial leads HYPOTHERMIA - Osborn J wave = repolarization abnormality at QRSST junction at temp. <32*C (best seen in mid/lat precordial leads); resolves with warming - early STE - bradycardia - muscle tremor artefact - PR/QT prolongation - Afib <30*C - VF <28*C PRE-EXCITATION BER (incidence 1%; higher in younger pts., M>F, blacks>whites) - diffuse ST elevation (80-90% <2mm in prec. leads/0.5mm limbs) - upward concave early ST segment - large symmetric concordant T (usually <6mm prec./<5mm limbs) - notched/slurred terminal QRS - relative temporal stability - absence of reciprocal changes - ST/T wave ratio <0.25 (DDx pericarditis) LV ANEURYSM = local dilated LV post infarct - inc. risk of CHF, refractory vent. dysrhythmia, mural thrombus/ systemic embolus - persistent STE weeks postMI - absence of reciprocal changes or other acute ischemic changes BRUGADA SYNDROME = congenital mutation of Na channel affecting RV repolarization; predisposition to reentrant arrhythmias (ie. VT) - ST elevation in V1-V3 with down-sloping character +/RBBB morphology WELLENS SYNDROME = critical LAD stenosis >50% at origin - COMMON = large symmetric deep inverted Ts in precordial leads - RARE= smaller biphasic T waves

ECG NON-ACS DIAGNOSTIC CRITERIA

HYPERKALEMIA 6.5-7.5 = peaked Ts, short QTc, prolonged PR 7.5-8.0 = QRS widening, P flatten >10 = sinusoidal QRS, asystole, complete HB, VF HYPOKALEMIA - T wave flattening, prominent U wave, ST depression HYPOCALCEMIA - prolonged QTc HYPERCALCEMIA - short QTc, ST depression, T wave widening, short ST interval, poss. bradys/BBB-> complete HB HYPOMAGNESEMIA - prolonged PR/QTc, ST depression, QRS widening, precordial T flips HYPERMAGNESEMIA - prolonged PR/QTc, QRS widening MYOCARDITIS - extremely variable - A/V dysrhythmias, nonspecific ST/ T wave changes, long QTc, low QRS voltage - ventricular conduction abnormality predicts poor outcome - d/t infection, inflammation PERICARDITIS Stage I = ST elevation Stage II = ST resolution Stage III = T wave inversion Stage IV = T wave resolution - short downsloping PR interval (due to atrial irritation); best seen in V5V6 or inferior leads