History: 54 y.o. Male hx MI s/p PCI (years ago) presenting w/ chest pain 

-Non-radiating, non-exertional mid-sternal chest pain x1 hour, described as pressure associated w/ nausea and diaphoresis

Vitals: BP 146/90  | Pulse 78 | Resp 24  | SpO2 100% 

Pertinent PE

-Distressed, clutching chest, diaphoretic 

-Regular rhythm, normal heart sounds and intact distal pulses.

-Effort normal and breath sounds normal

EKG on arrival

EKG Interpretation: NSR. Diffuse ST elevations anterior leads with hyperacute T waves V2-V4. Reciprocal ST depression II, III, aVF (inferior leads)

Plan

-Cath lab activated!

-ASA, Brilinta (Ticagrelor), Heparin bolus and gtt, SL nitro

-Labs drawn: CBC, BMP, coags, troponin

Cath Lab Findings

-Acute thrombotic occlusion and 100% in stent restenosis of prior LAD stent

-DES placement to prox LAD

Teaching Points:

-STEMI Criteria according to ACC/AHA definition

• ≥ 2 mm of STE in V2 and V3 in men > 40 years old 
• ≥ 2.5 mm is required in men < 40 years old 
• ≥ 1.5 mm in women

 -STEMI Equivalents  

1) De Winter T wave: upsloping STD w/ tall T wave in V1-V4  

2) Wellen’s syndrome: chest pain free (leads V2, V3)

a) Type A: Biphasic T wave

b) Type B: Deep symmetric T wave inversion

3) Posterior MI (LCx or RCA) → obtain posterior EKG

a) STD V1-V3

b) Prominent R wave V1-V2

c) Upright TW V1-V3

4) RV MI → obtain R sided EKG

a) STE V1

5) STE aVR with diffuse STD

6) TWI in aVL → impending inferior wall + mid LAD → serial EKG’s

7) Hyperacute TW: ≥ 2 contiguous leads, broad, asymmetric, tall upright TW V1-V6

8) 1st diagonal branch of LAD occlusion

a) STE aVL + V2

b) Upright TW in aVL + V2

c) STD + TWI in III + aVF