Excessive discordant ST elevation

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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Once upon a time, a new Left Bundle Branch Block (LBBB) was considered to be a STEMI-equivalent requiring emergency reperfusion. Later on it was found that there were far too many false positives if everyone with a new (or presumed new) LBBB was sent to the cath lab, so this rule was removed from the ACC/AHA guidelines in 2013.ref This means that now we need to look closer at the ECGs of patients with LBBB to find other signs to diagnose those who do have an acute infarction.

Wide complex rhythms such as LBBB can be difficult to interpret because they can cause abnormal ST segments even without any acute ischemia on top.ref These changes are often called secondary ST changes because the real primary problem is the abnormal QRS. But what if a patient has both a LBBB and acute ischemia?

Previously it was thought to be impossible to interpret the ST segments in the presence of a LBBB. This is no longer true, as we now have validated criteria to help us interpret these ST segments as normal or abnormal. The key concept involved is being able to tell the difference between concordant and discordant ST segments.

  • Concordant ST changes occur in the same direction as the QRS. So, if the QRS is positive, ST elevation is a concordant change. If the QRS is negative, ST depression is a concordant change.
  • Discordant ST changes occur in the opposite direction to the QRS. If the QRS is positive, ST depression is a discordant change. If the QRS is negative, ST elevation is a discordant change.

In 1996, Sgarbossa et al. published a set of criteria to help diagnose acute myocardial infarction in the presence of a Left Bundle Branch Block. Each criteria had independent predictive value for infarction, but together they were also developed as a scoring system where a total score of 3 or more equated to a 90% specificity for acute infarction.

The 3 original criteria included:

  1. Concordant ST elevation > 1mm in leads with a positive QRS complex (score 5)
  2. Concordant ST depression > 1 mm in V1-V3 (score 3)
  3. Excessively discordant ST elevation > 5 mm in leads with a -ve QRS complex (score 2).

In 2012, the original Sgarbossa criteria were modified by Smith et al. because the third criteria (>5mm rule) did not account for smaller QRS complexes that were followed by ST changes out of proportion to their size. (There were some other limitations to the study as well.ref)

The Smith-modified Sgarbossa criteria are:

  1. ≥ 1 lead with ≥1 mm of concordant ST elevation
  2. ≥ 1 lead of V1-V3 with ≥ 1 mm of concordant ST depression
  3. ≥ 1 lead with ≥ 1 mm ST elevation that is out of proportion to the size of the QRS, as defined by ≥ 25% of the depth of the preceding S-wave.

Unlike the original point scoring criteria, if any of the modified criteria are present then the cath lab should be activated.

Accurate measurements are critical in using this criteria. To be precise, the depth of the S wave should be measured in reference to the PR segment. The height of the ST segment should also be measured in reference to the PR segment and at the J point.

The modified Sgarbossa criteria have undergone external validation and found to perform better than the original criteria.ref This means that it is time they were more widely used in everyday clinical practice.

Steven Fruitsmaak

Back in 1996, Sgarbossa et al. also studied ST changes in ventricular-paced rhythms. They found that similar criteria was useful in this setting, i.e. concordant ST elevation, concordant ST depression in V1-3, or excessive discordant ST elevation >5mm was also reasonably specific for acute infarction in patients with a ventricular pacemaker. The sensitivity of these signs is low, meaning that you can't rule out infarction based on the absence of these signs.

So far there is limited data available for using this criteria in other wide complex rhythms such as Accelerated Idioventricular Rhythm (AIVR), but there are some case studies suggesting that it might be relevant for these rhythms too. Case studies have also shown that it is possible to see evidence of coronary occlusion in Ventricular Ectopic Beats (VEBs), even if the underlying rhythm does not always show ST changes.

Right Bundle Branch Block (RBBB) doesn't need the Sgarbossa criteria because it doesn't usually have any associated ST elevation. Any ST elevation is suspicious for MI in the presence of a RBBB!

There are some exclusions and limitations of the Sgarbossa criteria. In both of the original studies, patients were excluded if they had severe hypertension, acute heart failure (pulmonary oedema), extreme tachycardia, or hyperkalemia. In these conditions the ECG can be very abnormal but the first priority should be stabilising the patient.ref

Left Ventricular Hypertrophy (LVH) also causes secondary ST changes and in that setting these criteria have not been found to be very sensitive thus far.ref LVH is known to cause variation in ST segments over time even without ischemia, so even comparing with old ECGs can be difficult.ref

It is also important to note that none of these criteria have 100% sensitivity or specificity. There may still be a critical lesion even when the modified criteria are negative. They are probably most useful in stable patients who present with typical chest pain suggestive of MI.ref Serial ECGs, careful monitoring and clinical judgement remain very important in managing these patients.ref

ECG Library (28)

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In the ECGquest archives, this ECG has been tagged with: - Chest pain 12-Lead Excessive discordant ST elevation Pacemaker spikes Ventricular pacemaker Dr Smith's ECG Blog CC BY-NC
Acute chest pain in a patient with cardiomyopathy and a paced rhythm.

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.

In the ECGquest archives, this ECG has been tagged with: - 12-Lead Concordant ST depression in V1-V3 Excessive discordant ST elevation Atrial pacemaker Ventricular pacemaker Acute Inferior MI Acute Lateral MI Acute Posterior MI Positive Sgarbossa criteria Dr Smith's ECG Blog CC BY-NC
Can you see through this paced rhythm?

This ECG is from an elderly woman who presented with 2 hours of chest pain on a background of multiple stents, a pacemaker, stroke and COPD.

This ECG shows paced rhythm with excessively discordant ST segments (modified Sgarbossa positive). The cause was a 95% thrombotic lesion of the RCA.

In the ECGquest archives, this ECG has been tagged with: - Abdominal pain 12-Lead Excessive discordant ST elevation Wide QRS Positive Sgarbossa criteria Dr Smith's ECG Blog CC BY-NC
Following Criteria Exactly, even the Modified Sgarbossa Criteria, Can Be Deadly – ECG 2

This ECG is from a man in his 70s who presented with epigastric pain.

This ECG shows These discordant ST changes are excessive and do meet Modified-Sgarbossa criteria. This was missed. The patient went into VF shortly after and died.

In the ECGquest archives, this ECG has been tagged with: - Chest pain Dyspnoea 12-Lead Wandering baseline Excessive discordant ST depression. Excessive discordant ST elevation Pacemaker spikes Regular Tachycardia Ventricular pacemaker Wide QRS Multi-vessel disease Dr Smith's ECG Blog CC BY-NC
Can you see through this wide complex rhythm?

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.

In the ECGquest archives, this ECG has been tagged with: - Chest pain Chest leads Concordant ST elevation Excessive discordant ST elevation Ventricular pacemaker Wide QRS Acute Anterior MI Dr Smith's ECG Blog CC BY-NC
Anterior MI in paced rhythm, dismissed by cardiologist, patient died.

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.

In the ECGquest archives, this ECG has been tagged with: - Chest pain Dyspnoea 12-Lead Excessive discordant ST depression. Excessive discordant ST elevation Left Axis Deviation R in aVR Regular Tachycardia Ventricular tachycardia Wide QRS Acute Lateral MI Acute Posterior MI Dr Smith's ECG Blog CC BY-NC
Posterolateral OMI resulting in VT, then R-on-T phenomenon and VF – repeat after sudden worsening of shortness of breath.

This ECG is from a man in his 50s who presented with 1 hour of chest pain and shortness of breath. This was his second ECG after he suddenly became more short of breath.

In the ECGquest archives, this ECG has been tagged with: - Chest pain 12-Lead Excessive discordant ST elevation LBBB Acute Inferior MI Positive Sgarbossa criteria Dr Smith's ECG Blog CC BY-NC
A 60-something year old man with chest pain and a wide QRS

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.

In the ECGquest archives, this ECG has been tagged with: - Dyspnoea 12-Lead Discordant ST changes Excessive discordant ST elevation Pacemaker spikes Ventricular pacemaker Dr Smith's ECG Blog CC BY-NC
Patient with Paced Rhythm in Severe Cardiomyopathy Presents with SOB due to Acute Decompensated Heart Failure

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.

In the ECGquest archives, this ECG has been tagged with: - Chest pain 12-Lead Excessive discordant ST elevation Normal Axis Reciprocal ST depression LBBB Acute Lateral MI Dr Smith's ECG Blog CC BY-NC
Left Bundle Branch Block, Severe Chest pain, Previous Normal Angio. What is going on? Repeat ECG 24 min later.

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.

In the ECGquest archives, this ECG has been tagged with: - Chest pain 12-Lead Concordant ST depression in V1-V3 Excessive discordant ST elevation Extreme Axis Regular Ventricular pacemaker Wide QRS Positive Sgarbossa criteria Dr Smith's ECG Blog CC BY-NC
Chest pain, Ventricular Paced Rhythm, and a Completely Normal Angiogram 3 Months Prior.

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.