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.

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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. 30408

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? 30424

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 30441

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 Wide QRS Ventricular pacemaker Multi-vessel disease Dr Smith's ECG Blog CC BY-NC
Can you see through this wide complex rhythm? 28777

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 Wide QRS Ventricular pacemaker Acute Anterior MI Dr Smith's ECG Blog CC BY-NC
Anterior MI in paced rhythm, dismissed by cardiologist, patient died. 27755

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 Wide QRS Ventricular tachycardia 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. 27573

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 25466

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 25168

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. 29116

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 Wide QRS Ventricular pacemaker Positive Sgarbossa criteria Dr Smith's ECG Blog CC BY-NC
Chest pain, Ventricular Paced Rhythm, and a Completely Normal Angiogram 3 Months Prior. 22362

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.

In the ECGquest archives, this ECG has been tagged with: - Chest pain 12-Lead Serial 12-lead Anterior ST elevation Concordant ST elevation Excessive discordant ST elevation Left Axis Deviation Normal rate Pacemaker spikes Wide QRS Ventricular pacemaker Acute Anterior MI ECG of the Week CC-BY-NC-SA
ECG of the Week – 25th December 2017 – 60 min later 16356

This ECG is from a woman in her 80s who presented with chest pain. She had a history of 2nd degree AV block with PPM in-situ. This repeat ECG was recorded 60 min after presentation when she had further chest pain.

This ECG shows ventricular pacing with concordant ST elevation in I and V6, and excessive discordant ST elevation in V2-4. The cause was an acute anterior MI.

In the ECGquest archives, this ECG has been tagged with: - Dyspnoea Fatigue 12-Lead Serial 12-lead Excessive discordant ST elevation Pacemaker spikes Ventricular pacemaker Acute Inferior MI Acute Posterior MI Dr Smith's ECG Blog CC BY-NC
See what happens when one fails to diagnose STEMI in LBBB and Paced Rhythm 3 – later that night 15688

This ECG is from a female in her 60s presented with 2-3 days of fatigue and shortness of breath. She called EMS when her symptoms acutely worsened while she was shopping. EMS arrived and recorded a heart rate of 27. On arrival to the ED she was noted to be in complete heart block. She was given atropine with transient increase in HR to 80s. This ECG was recorded later that night after a transvenous pacemaker was placed.

This ECG shows ventricular paced rhythm with excessive discordant ST elevation in II, III and aVF. There is reciprocal depression in aVL and I. The cause was an occluded proximal right coronary artery. This diagnosis was delayed and the patient died.