When ECG findings should prompt consideration of coronary angiograph

ECG Findings That Should Prompt Consideration of Coronary Angiography

1.    ST-Elevation Myocardial Infarction (STEMI)

·        ECG Findings:

·        ST-Elevation: New, significant ST-segment elevation in two or more contiguous leads.

·        Reciprocal Changes: ST-segment depression in opposite leads (though not always seen, especially if the MI involves the posterior wall).

·        Indication for Angiography:

·        Coronary angiography is urgent and necessary to identify the location of the coronary artery occlusion and to perform percutaneous coronary intervention (PCI) if appropriate.

2.    Non-ST-Elevation Myocardial Infarction (NSTEMI)

·        ECG Findings:

·        ST-Segment Depression: Persistent ST-segment depression in two or more contiguous leads.

·        T-Wave Inversions: Deep or symmetrical T-wave inversions, especially in the anterior leads (V1-V4).

·        Indication for Angiography:

·        NSTEMI patients should undergo coronary angiography to assess the severity and extent of coronary artery disease, usually within 24 to 72 hours, depending on risk stratification.

3.    Unstable Angina

·        ECG Findings:

·        ST-Segment Depression: Transient or persistent ST-segment depression.

·        T-Wave Inversions: New or worsening T-wave inversions.

·        Non-Specific Changes: Sometimes only subtle changes or normal ECG, but with high clinical suspicion based on symptoms.

·        Indication for Angiography:

·        Unstable angina often warrants coronary angiography to evaluate for significant coronary artery stenosis that may require revascularization.

4.    New Left Bundle Branch Block (LBBB) with Chest Pain

·        ECG Findings:

·        LBBB Pattern: Broad QRS complexes (>120 ms) with an absence of Q waves in leads I, V5, and V6, and an abnormal R wave in these leads.

·        Indication for Angiography:

·        New LBBB in the presence of chest pain is considered an equivalent to STEMI and warrants urgent coronary angiography.

5.    Posterior Myocardial Infarction

·        ECG Findings:

·        ST-Segment Depression in V1-V3: Horizontal ST-segment depression, often indicating a posterior MI.

·        Tall R Waves in V1-V3: Corresponding posterior ST-elevation that may be visible as ST depression in the anterior leads.

·        Dominant R Wave in V2: Often accompanied by upright T waves.

·        Indication for Angiography:

·        Posterior MI typically involves the circumflex artery and requires coronary angiography to confirm and treat the occlusion.

6.    Wellens’ Syndrome (Critical Proximal LAD Stenosis)

·        ECG Findings:

·        Deeply Inverted or Biphasic T Waves: Typically in the precordial leads (V2-V4), indicative of critical stenosis in the left anterior descending artery (LAD).

·        Indication for Angiography:

·        This pattern is highly suggestive of critical proximal LAD stenosis, and patients should undergo urgent coronary angiography to prevent imminent anterior wall MI.

7.    ST-Segment Elevation in AVR with Widespread ST Depression

·        ECG Findings:

·        ST-Elevation in aVR: Accompanied by diffuse ST-segment depression in other leads.

·        ST Depression in I, II, V4-V6: Indicates left main coronary artery (LMCA) or severe triple vessel disease.

·        Indication for Angiography:

·        This pattern suggests significant LMCA disease or severe triple-vessel disease, requiring urgent coronary angiography and possible intervention.

8.    Hyperacute T-Waves

·        ECG Findings:

·        Broad, Tall T-Waves: Often the earliest sign of myocardial infarction, especially in the anterior leads.

·        Indication for Angiography:

·        Hyperacute T-waves suggest an evolving MI, warranting immediate coronary angiography to assess and treat the occluded artery.

9.    De Winter’s T-Waves

·        ECG Findings:

·        Upsloping ST-Depression: With peaked T-waves in the precordial leads (V1-V6).

·        Indication for Angiography:

·        This pattern is associated with a proximal LAD occlusion and is considered an indication for emergent coronary angiography.

10. Spontaneous Coronary Artery Dissection (SCAD)

·        ECG Findings:

·        ST-Segment Elevation or Depression: Variable based on the extent and location of the dissection.

·        T-Wave Abnormalities: Can also be seen in some cases.

·        Indication for Angiography:

·        SCAD requires coronary angiography for diagnosis and to guide treatment, which may include conservative management or revascularization depending on the severity.

11. Prinzmetal’s (Variant) Angina

·        ECG Findings:

·        Transient ST-Segment Elevation: Occurring at rest, typically in the early morning, and resolving spontaneously.

·        Indication for Angiography:

·        Although the ST-elevation is transient, coronary angiography is often indicated to rule out underlying significant coronary artery disease and to confirm the diagnosis.

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These ECG findings prompt consideration of coronary angiography to confirm the diagnosis and guide appropriate management, potentially including PCI or surgical intervention. This detailed information provides essential guidance for general practitioner MDs, helping them make timely and informed decisions in emergency situations.