ST SEGMENT

Adityo Wibhisono
•ST segment yang normal flat, segaris
isoelectric pada EKG antara gelombang
S (the J point) dan awal gelombang T.
•Hal ini menunjukkan antara ventricular
depolarization and repolarization.
•Penyebab paling penting dari kelainan
ST segment (elevasi atau depressi)
adalah myocardial ischaemia atau
infarction
Penyebab Dari ST Segment Deperessi

Mycoradial Iscahemic / NSTEMI

Perubahan Reciprocal STEMI
Posterior MI
Efek Digoxin
Supraventricular tachycardia
Right Ventricular hyperthrophy
Left Bundle Branch Block
Left Ventricular Hypethrophy
Ventricular paced rhytm
 Morphology of ST Depression

•ST depressi dapat berupa upsloping,

downsloping, atau horizontal.
•Horizontal atau downsloping ST depressi
≥ 0.5 mm pada J-point dan ≥ 2 leads indikasi
myocardial ischaemia
•Upsloping ST depressi pada lead precordial
dengan prominent “De Winter’s” pada
gelombang T highly specific untuk occlusion
of the Left Anterior Descending.
•Perubahan Reciprocal dari morphologi ST ST depression: upsloping (A), downsloping (B), horizontal (C)
elevasi dan akan terlihat pada lead yang
berlawanan dari posisi infarct.
•Posterior MI manifestasi pada horizontal ST
depressi pada V1-3
 Patterns of ST Depression
Myocardial ischaemic

ST depression due to subendocardial

ischaemia may be present in a variable
number of leads and with variable
morphology. It is often most prominent
in the left precordial leads V4-6 plus
leads I, II and aVL. Widespread ST
depression with ST elevation in aVR is
seen in left main coronary artery
occlusion and severe triple vessel
disease.

Left Main Coronary Artery Occlusion

 Patterns of ST Depression
Reciprocal Change
ST elevation during acute STEMI is associated with simultaneous ST depression in the electrically opposite
leads:
•Inferior STEMI produces reciprocal ST depression in aVL (± lead I).
•Lateral or anterolateral STEMI produces reciprocal ST depression in III and aVF (± lead II).
•Reciprocal ST depression in V1-3 occurs with posterior infarction .

Reciprocal ST depression in aVL with inferior STEMI

 Patterns of ST Depression
Reciprocal Change

Reciprocal ST depression in III and aVF with high lateral STEMI

 Patterns of ST Depression
Posterior Myocardial Infarction

Acute posterior STEMI causes ST depression in the anterior leads V1-3, along with dominant R waves
(“Q-wave equivalent”) and upright T waves. There is ST elevation in the posterior leads V7-9.

Posterior MI
 Patterns of ST Depression
De Winters T Wave

This pattern of upsloping ST depression with symmetrically peaked T waves in the precordial leads is
considered to be a STEMI equivalent, and is highly specific for an acute occlusion of the LAD.

De Winter’s T Waves
 Patterns of ST Depression
Digoxin Effect
Digoxin effect refers to the presence on the ECG of:
Downsloping ST depression with a characteristic “sagging” morphology, reminiscent of
Salvador Dali’s moustach
•Flattened, inverted, or biphasic T waves.
•Shortened QT interval.

Sagging ST segments are most evident in the lateral leads V4-6, I and aVL.
 Patterns of ST Depression
Hypokalaemia

Hypokalaemia causes widespread downsloping ST depression with T-wave flattening/inversion,

prominent T waves and a prolonged QT interval.

Hypokalaemia
 Patterns of ST Depression
Right Ventricular Hyperthrophy

RVH causes ST depression and T-wave inversion in the right precordial leads V1-3.

Right ventricular hypertrophy

 Patterns of ST Depression
Right Bundle Branch Block

RBBB may produce a similar pattern of repolarisation abnormalities to RVH, with ST depression and
T wave inversion in V1-3.

Right bundle branch block

 Patterns of ST Depression
Supraventricular tachycardia
Supraventricular tachycardia (e.g. AVNRT) typically causes widespread horizontal ST depression,
most prominent in the left precordial leads (V4-6). This rate-related ST depression does not
necessarily indicate the presence of myocardial ischaemia, provided that it resolves with treatment

AV-nodal re-entry tachycardia

 Ventrikel Flutter Ventrikel Takikardi

Ventrikel Fibrilation Supraventrikular Takikardia

 Thank You
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20;324(7343):963-6. Review. PubMed PMID: 11964344; PubMed Central PMCID: PMC1122906. Full text.
•Phibbs BP. Advanced ECG: Boards and Beyond (second edition). Elsevier 2006.
•Smith SW. T/QRS ratio best distinguishes ventricular aneurysm from anterior myocardial infarction. Am J Emerg Med. 2005
May;23(3):279-87. PubMed PMID: 15915398.
•Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice (6th edition), Saunders 2008.