STEMI equivalent

Hi guys,

I just had a quick advise from Dr Tony Smith that I’d like to share with you.

I was called for a R50 back up for STEMI pathway the other day. EMT/Para crew did well recognising the abnormal ECG and consulted Clinical Desk where they were advised to treat it as STEMI thus following STEMI pathway. I could not get the actual copy by here is an ECG pretty similar from LIFL.

This female pt (we had) was in 60s, presenting with epigastric pain lasting for few hours, pale, clammy, with history of AAA ? size.

The point of this blog is to clarify the criteria for the STEMI pathway so I’m not going talk about the specifics of this ECG but please read the LIFL page if you are not familiar with this ECG pattern .

Our STEMI pathway podcast explains why we should not be sending “Interesting ECG such as STEMI mimics”, and I was slightly confused why this case was an exception.
The presentation wasn’t pointing clearly to myocardial ischaemia and I was also concerned about aortic dissection.

Here is the answer from our medical director Dr Tony Smith;

Q: Should we be treating STEMI equivalent (not mimics) as STEMI such as this case?
A: This is controversial. We could not get agreement on this at the national cardiac network and thus is not included in our current criteria for STEMI for that reason.

Just to re-confirm, the current STEMI pathway is for ECGs showing STEMI and STEMI mimics and equivalents (Yes, Wellens, De Winter Ts etc you ECG geeks, lol) are not included at this stage.

Saying that, we don’t want to end up with under-triaging so please have low threshold to consult if in doubt.

Rebel EM summarises teaching of Dr Amal Mattu including; 

  • STE in aVR Should be Concerning IF you have a patient with:
    • Worrisome/Concerning Symptoms (Cardiopulmonary Symptoms) AND…
    • ST-Segment Depression in Several Other Leads
  • Don’t worry so much about STE 0.5mm or less in lead aVR, because it lacks specificity.  Using 1.0mm or greater in lead aVR, has better specificity
  • Patients with ACS due to LMCA Blockage, Triple Vessel Disease, or Proximal LAD Blockage will look “sick” due to global cardiac ischemia.  This narrows the number of patients we would consider activating the cath lab for with STE in aVR.

The author also highlight the differentials in the following paragraph.

What Else can Cause STE in aVR that Won’t Benefit from Going to the Cath Lab?

Worrisome Diagnoses:

  • Thoracic Aortic Dissection
  • Massive Pulmonary Embolism
  • Massive Gastro Intestinal Hemorrhage

A recent retrospective cohort study concluded “the present study does not suggest the use of aVR elevation as an indication for urgent angiography”.

OK I hope this may help some of you wondering about the subject.



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