Table 1.
STEMI Criteria Vs Evidence-Based OMI Findings
| STEMI Criteria | OMI |
|---|---|
| Defined by ECG | Clinical: ACS with refractory ischemia, hemodynamic or electrical instability is indication for immediate angiography regardless of ECG Echo: bedside ultrasound can identify new regional wall motion abnormalities |
| Must have ST-segment elevation | Ischemic STDmaxV1-4 identifies posterior OMI with 97% specificity |
| Hyperacute T waves (large relative to QRS, look inflated with large area under the curve) | |
| de Winter T waves (ST-segment depression rising into hyperacute T waves) | |
| Wellens waves (reperfusion T-wave inversion) identifies spontaneous reperfusion with risk of reocclusion | |
| ST-segment elevation in at least 2 contiguous leads | South African flag pattern (STE in noncontiguous leads V2 and aVL, with inferior reciprocal STD) identifies first diagonal occlusion |
| Aslanger pattern (STE in III with reciprocal STD I/aVL, ST in V1>V2 and STD V5-V6) indicates inferior OMI with concomitant critical stenosis | |
| ST-segment elevation must be at least 1 mm | Pericarditis results in false positive STEMI while many inferior OMI are false negative STEMI, but primary STD-aVL is 99% sensitive for inferior OMI and excludes pericarditis |
| ST-segment elevation in V2-V3 must be at least 1.5 mm in women, 2 mm in men >40, and 2.5 in men <40 | Early repolarization results in false positive STEMI while many LAD occlusion are false negative STEMI. Any ischemic abnormality (Q wave in V2-V3, terminal QRS distortion in V2-V3, convex ST-segment, precordial STD or TWI, or inferior reciprocal change) excludes BER as a cause of anterior STE. The 4 variable formula (using QRS in V2, STE in V3, R in V4, and QTc) differentiates subtle LAD occlusion from BER |
| STEMI defined as ST-segment elevation in the absence of LBBB | Smith-Modified Sgarbossa criteria (any lead with concordant STE, concordant STD V1-V3, or discordant STE/S >25%) identifies OMI in LBBB or ventricular paced rhythm |
| Q waves regarded as old or completed infarcts | Anterior QS waves with ST-segment elevation can be from LV aneurysm (resulting in false positive STEMI) or acute LAD occlusion (resulting in false negative STEMI), but any lead V1-V4 with T/QRS >0.36 identifies acute LAD occlusion and differentiates it from LV aneurysm |
BER = benign early repolarization; ECG = electrocardiogram; LBBB = left bundle branch block; OMI = occlusion myocardial infarction; QTc = corrected QT interval; STD = ST-segment depression; STEMI = ST-segment elevation myocardial infarction.