High-Risk EKG Patterns Not to Miss
Flashcards covering Wellens syndrome, de Winter T waves, aVR elevation, and posterior MI as STEMI equivalents.
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Questions Covered in This Set
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What is a "STEMI equivalent"?
An EKG that does not meet ST-elevation criteria but identifies a patient with acutely threatened myocardium who needs urgent catheterization.
What are the criteria for Wellens syndrome?
Recent anginal chest pain now RESOLVED, <1 mm ST elevation, no Q waves, preserved R waves in V2–V4, normal or minimally elevated troponin, plus characteristic T-wave changes in V2–V4.
Wellens Type A vs Type B
Type A (25%): biphasic T waves in V2–V3 (up then down). Type B (75%): deep, symmetric, inverted T waves in V2–V4.
Why must you NOT stress-test a Wellens patient?
The pattern reflects a critical proximal LAD lesion that is only temporarily patent; a treadmill can re-occlude the artery. They need angiography — ~75% of untreated patients infarct within weeks.
Describe the de Winter T-wave pattern
Upsloping ST depression of 1–3 mm at the J point in V1–V6 with tall, symmetric, peaked T waves rising out of it, often with 1–2 mm ST elevation in aVR and no anterior ST elevation.
How do you distinguish Wellens from de Winter?
Wellens: pain-FREE, inverted or biphasic T waves, artery currently open. de Winter: actively in PAIN, ST depression with tall upright T waves, LAD occluded right now.
What does ST elevation in aVR with diffuse ST depression suggest?
Global subendocardial ischemia — left main disease, proximal LAD, or severe three-vessel disease. Criteria: aVR elevation ≥1 mm, greater than V1, with ST depression in ≥6 leads (I, II, V4–V6).
Non-coronary causes that mimic the aVR elevation pattern
Any supply–demand mismatch: severe anemia, tachyarrhythmia, aortic stenosis, sepsis, or pulmonary embolism — treat the patient, not just the tracing.
How does a posterior MI appear on a standard 12-lead?
As a mirror image in V1–V3: horizontal ST depression ≥0.5 mm, tall R waves (R/S ratio >1 in V2), and tall upright T waves — because there is no electrode over the back of the heart.
Which arteries typically cause posterior MI?
The left circumflex, or a dominant right coronary artery (RCA).
