NSTEMI, Unstable Angina, and STEMI Mimics
Key EKG features separating true ischemia from pericarditis, LVH, early repolarization, and Brugada pattern.
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Questions Covered in This Set
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What separates unstable angina from NSTEMI?
The troponin. Both can show identical EKGs (normal, ST depression, or T inversion); unstable angina has negative troponin (ischemia without cell death), NSTEMI has positive troponin (subendocardial infarction).
Does a normal EKG exclude ACS?
No — roughly 1 in 20 patients with a normal initial EKG still have ACS. Repeat EKGs every 15–30 minutes during ongoing pain and draw serial troponins.
What are the EKG hallmarks of NSTEMI?
Horizontal or downsloping ST depression ≥0.5 mm and/or deep symmetric T-wave inversions, often diffuse across many leads without a neat territorial pattern or reciprocal changes.
ST depression maximal in V2–V4 with upright T waves plus ST elevation in aVR suggests what?
Severe left main or three-vessel disease — a high-risk pattern, not a simple regional NSTEMI.
Describe the classic pericarditis EKG.
Diffuse concave-upward ('saddle-shaped') ST elevation ignoring coronary territories, PR depression (especially lead II), PR elevation in aVR, and Spodick's sign (downsloping TP segment). No Q waves; no reciprocal depression except aVR/V1.
How does the V6 ST/T ratio distinguish pericarditis from early repolarization?
ST-elevation/T-wave amplitude ratio in V6 >0.25 suggests pericarditis; <0.25 suggests benign early repolarization.
How does T-wave timing differ between pericarditis and STEMI?
In pericarditis T waves don't invert until the ST segments return to baseline; in STEMI T waves invert while the ST segments are still elevated.
Why does LVH cause ST elevation in V1–V3?
Deep S waves in V1–V3 drag the ST segment up — 2–4 mm of concave elevation with tall T waves is normal and proportional to the huge QRS, with a lateral 'strain' pattern (ST depression, asymmetric T inversion).
What features define benign early repolarization?
Young healthy patients, concave 1–4 mm ST elevation mostly V2–V5, notched or slurred J point ('fish-hook'), tall symmetric T waves, stability over time, no reciprocal change, no PR depression.
What is a Type 1 Brugada pattern?
Coved ST elevation in V1–V2 descending into an inverted T wave with rSR' appearance — a sodium-channel disease with risk of sudden death from VF; unmasked by fever, cocaine, or Na-channel blockers.
