ST Elevation/Depression

Determining ST-T wave changes is essential to ECG

interpretation. It is with respect to the PR segment that ST
segment deviations (elevation or depression) are judged. The PR
segment is the connecting line that extends from the end of the P
wave until the beginning of the QRS complex (left Figure below).
We define:

ST Elevation IF the ST is above the PR baseline.
ST Depression IF the ST is below the PR baseline.


Note: The PR baseline is more difficult to see when the heart
rate is faster (the PR shortens with tachycardia). It may be
challenging to make out the PR baseline when there is artifact
with baseline wander



J-Point Elevation (right Figure above):
The J Point joins. It joins the two Ss (ie, the end of the
QRS with the beginning of the ST segment). A distinct J point is
not always seen (since the QRS complex and the ST segment often
imperceptibly blend into one another).

When it is seen the J point is often slightly elevated
(with respect to the PR baseline). This is often a normal
finding (known as early repolarization See next section).
The J point may be notched (especially with benign
repolarization variants).
In contrast it is uncommon for Acute MI to show J point
notching (but you may see notching with pericarditis).



The Shape of ST Elevation


The shape of ST elevation is more important than the amount
of elevation. Acute MI may occur with only minimal ST elevation.
ST segment elevation with an upward concavity (ie, "smiley"
configuration) is usually benign especially when seen in an
otherwise healthy, asymptomatic individual (especially when seen
with notching of the J point in one or more leads). This benign
normal variant is known as early repolarization.

In contrast, ST segment elevation with coving or a
downward convexity ("frowny" configuration) is much
more likely to be due to acute injury (from ischemia/MI ).


KEY Point History is ever important. Although ST elevation
with a "smiley" configuration and J point notching often
reflects a normal variant this is only true IF the patient is
asymptomatic. An identical smiley-shape ST pattern from a
patient with chest pain must be assumed acute until proven
otherwise. IF in doubt Admit the patient! Look for old
tracings to compare. Repeat the ECG.

Note There is an uncommon form of repolarization variant
that manifests with an ST coving (frowny) morphology.
The clue that this is likely to be benign lies in the history
the patient is usually a young, healthy athlete (often African-
American) who is asymptomatic. Having a prior tracing
for comparison may be invaluable. Were the patient to
present to an ED with chest discomfort and no prior tracing
for comparison this pattern would be indistinguishable
from that of acute MI. History is ever important!




Tracing R How would you interpret this ECG IF the patient was:
an asymptomatic young adult?
an adult with recent URI and pleuritic chest pain?
an older adult with severe new-onset chest pain?




Is Early Repolarization Truly Benign?
While it has long been thought that the incidental finding of
early repolarization (ER) in an otherwise healthy, asymptomatic
young-to-middle-aged adult is benign we now know that this
may not necessarily always be true.

Tikkanen et al (NEJM 361:2529, 2009) have shown a
1.3-fold increased risk of cardiac death with 1mm early
repolarization ST elevation (and up to a 3-fold increased risk
IF >2mm ST elevation). What to do with these results???
Early repolarization is common (2-5% of population).
Cardiac arrest is rare in these patients. Most ER is benign.
IF the paient is otherwise healthy and asymptomatic We
choose not to be concerned by the incidental finding of early
repolarization on a baseline tracing.
But Perhaps ER should be a marker to consider further
evaluation in those patients who also have a positive family
history of early sudden death or an episode of syncope/VT.



Answer to R: The rhythm is sinus at ~60/minute. The PR,
QRS, and QT intervals are normal. We estimate the axis at +60.
The sum of the S wave in lead V2 (~3 large boxes = 15 mm) plus the
R wave in V5 or V6 (~5 large boxes = 25 mm) clearly exceeds 35.
This satisfies voltage criteria for LVH (provided the patient is older
than 35).

QRST Changes A Q wave and T wave inversion is seen in
lead III (which as isolated findings may be normal). There
are small septal q waves in V5,V6. Transition is normal
between leads V3-to-V4.
The most remarkable finding is ST segment elevation in
multiple leads. ST segments manifest an upward concavity
(ie, smiley configuration), with J point notching (arrow in
lead V5 ) which for a young adult is consistent with early
repolarization.



We emphasize that our interpretation of Tracing R would be very
different:
IF instead, the patient was a young adult with recent URI
and pleuritic chest pain in which case the diffuse ST
elevation would clearly be consistent with acute
pericarditis. A rub would clinch the diagnosis.
IF the patient was an older adult with risk factors and
new-onset chest pain in which case acute MI would
have to be ruled out despite the smiley-shape of the ST
segment elevation.


KEY Clinical Point: In each case above, our Descriptive
Analysis does not change. Instead it is the clinical history
that determines our interpretation. Repeating the ECG in a little
while (to see if there are any evolutionary changes) and
seeking a prior ECG (for comparison) would also help to clarify
the situation.