Excessive discordant ST elevation is a subtle but important sign of infarction in the presence of a wide QRS complex. It was first defined as ST elevation of 5 mm or more, but this rule has been modified to suggest that it is abnormal if the ST elevation is more than 25% of the height of the S wave. Alternatively, a cutoff of 20% is less specific but slightly more sensitive.
See also: ST segment
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This ECG is from a woman in her 70s who was awoken with sharp chest pain on a background of cardiomyopathy, ICD and LVH.
This ECG shows paced rhythm with modified-Sgarbossa positive discordant ST elevation in I, aVL and V2. Angiogram did not find a culprit and echo did not find a wall motion abnormality. The cause remains a mystery.
This ECG is from a man in his 70s who presented with intermittent dyspnoea and chest pain over the past 2 weeks. He had a history of a pacemaker, heart failure, aortic stenosis, diabetes, hypertension, stroke, ischemic heart disease, chronic kidney disease and peripheral vascular disease. This was his initial ECG.
This ECG shows a wide complex tachycardia with ventricular pacing. The excessively discordant ST changes in V4-6 and aVR suggested diffuse subendocardial ischemia. He was found to have severe three vessel disease and a proximal left circumflex stenosis was stented.
This ECG is from an elderly male who presented with chest pain. He has a pacemaker. This was his second prehospital ECG.
This ECG shows ventricular paced rhythm with excessive discordant ST elevation in V3 as well as concordant ST elevation in V2 and V4. The cause was most likely a proximal LAD or left main occlusion. This was missed and the patient died.
This ECG is from a man in his 60s who presented with chest pain for several hours on a background of prior coronary artery disease and hypertension.
This ECG shows LBBB with excessively discordant ST elevation in inferior leads with reciprocal changes in I and aVL. The cause was a RCA in-stent restenosis.
This ECG is from a middle-aged male who presented with paroxysmal nocturnal dyspnoea and hypoxia on a background of heart failure, biventricular pacemaker, ICD and previous LV thrombus.
This ECG shows biventricular paced rhythm with RBBB-like morphology and discordant ST elevation in I, aVL, V3-5 due to acutely decompensated heart failure.
This ECG is from a middle aged woman who presented with sudden severe substernal chest pain on a background of idiopathic cardiomyopathy and biventricular failure.
This ECG shows LBBB (not paced rhythm) with excessive discordant ST elevation in III and aVF with reciprocal change in aVL. The cause was an acute lateral MI, likely due to embolism from a left atrial appendage thrombus.
This ECG is from an elderly woman who presented with chest pain on a background of a normal angiogram 3 months prior.
This ECG shows ventricular paced rhythm (likely biventricular) with concordant ST depression in III, aVF and V3. There is excessive discordant ST elevation in I and aVL. The cause was an acute left main occlusion due to suspected embolism.