Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Review
. 2017 Jun;18(4):601-606.
doi: 10.5811/westjem.2017.1.32699. Epub 2017 Apr 17.

Pitfalls in Electrocardiographic Diagnosis of Acute Coronary Syndrome in Low-Risk Chest Pain

Semhar Z Tewelde  1 , Amal Mattu  1 , William J Brady Jr  2
Affiliations
Review

Pitfalls in Electrocardiographic Diagnosis of Acute Coronary Syndrome in Low-Risk Chest Pain

Semhar Z Tewelde et al. West J Emerg Med. 2017 Jun.

Abstract

Less than half of patients with a chest pain history indicative of acute coronary syndrome have a diagnostic electrocardiogram (ECG) on initial presentation to the emergency department. The physician must dissect the ECG for elusive, but perilous, characteristics that are often missed by machine analysis. ST depression is interpreted and often suggestive of ischemia; however, when exclusive to leads V1-V3 with concomitant tall R waves and upright T waves, a posterior infarction should first and foremost be suspected. Likewise, diffuse ST depression with elevation in aVR should raise concern for left main- or triple-vessel disease and, as with the aforementioned, these ECG findings are grounds for acute reperfusion therapy. Even in isolation, certain electrocardiographic findings can suggest danger. Such is true of the lone T-wave inversion in aVL, known to precede an inferior myocardial infarction. Similarly, something as ordinary as an upright and tall T wave or a biphasic T wave can be the only marker of ischemia. ECG abnormalities, however subtle, should give pause and merit careful inspection since misinterpretation occurs in 20-40% of misdiagnosed myocardial infarctions.

PubMed Disclaimer

Conflict of interest statement

Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.

Figures

Figure 1
Figure 1
The Forgotten Lead. Diffuse ST depression with ST elevation in aVR>1mm and subtle ST elevation in V1; ST elevation in aVR>V1.
Figure 2
Figure 2
Posterior acute myocardial infarction (AMI). Anteroseptal (V1–V3/4) ST depression with tall R waves and upright T waves.
Figure 3
Figure 3
Inferior AMI. High lateral (I, aVL) ST depression with inferior (II, III, aVF) ST elevation.
Figure 4
Figure 4
Tall T wave V1. Broad upright T wave V1>V6 with subtle septal (V1–V2) ST elevation and anterolateral (V4–V6, I) ST depression.
Figure 5
Figure 5
Wellens’ syndrome. Biphasic T waves V2–V3 with minimal ST elevation.
See this image and copyright information in PMC

References

    1. Pitts SR, Niska RW, Xu J, et al. National Health Statistics Reports. US Dept of Health and Human Services National hospital ambulatory medical care survey: 2006 emergency department summary. - PubMed
    1. Amsterdam EA, Kirk JD, Bluemke DA, et al. A scientific statement from the American Heart Association. Testing of low-risk patients presenting to the emergency department with chest pain. Circulation. 2010;122(17):1756–76. - PMC - PubMed
    1. Backus BE, Six AJ, Kelder JH, et al. Risk scores for patients with chest pain: evaluation in the emergency department. Curr Cardiol Rev. 2011;7(1):2–8. - PMC - PubMed
    1. Sanchis J, Bodí V, Núñez J, et al. Limitations of clinical history for evaluation of patients with acute chest pain, non-diagnostic electrocardiogram, and normal troponin. Am J Cardiol. 2008;101(5):613–7. - PubMed
    1. Schillinger M, Sodeck G, Meron G, et al. Acute chest pain--identification of patients at low risk for coronary events. The impact of symptoms, medical history and risk factors. Wien Klin Wochenschr. 2004;116(3):83–9. - PubMed

MeSH terms