Dan's Soapbox 1 - What's Hot in EM

1. Dan’s Soapbox 1
What’s hot in EM?

2. Dr Smith’s ECG Blog

3. 58 year old man, intermittent chest
pain for 2 weeks

4. Pain settled spontaneously. Serial
Troponins negative

5. ST elevation Vs early repolarisation
• Benign early repolarisation
– Widespread concave ST elevation ST
– Most commonly V2 – V5
– Notching is common at J point
– Rare > 50 years
– ST elevation is usually less than 2mm in precordial
leads, but can be more
– < 0.5mm in limb leads
– No reciprical ST segment changes
– Normal R wave progression
– Changes are relatively stable

8. Repeat ECG 12 hours later!!!

11. How good is it?
• Retrospective review
• Subtle anterior STEMI admitted to cardiology with
proven LAD occlusion Vs ED coded non cardiac chest
pain with BER
• Mathematical formula comparing:
– Height of ST elevation
– QTc interval
– R wave progression
• Actual calculation
– (1.196 x ST-segment elevation 60 ms after the J point in
lead V3 in mm) + (0.059 x QTc in ms) - (0.326 x R-wave
amplitude in lead V4 in mm)

12. Seems Complicated?
• The greater the ST elevation  more likely to be
STEMI
• The longer the QTC  more likely to be STEMI
• Poor R wave progression (small R wave in V4) 
more likely to be a STEMI
– A value of >23.4 was found to predict STEMI
– </= 23.4 predicted early repolarization
• Sensitivity 86%
• Specificity 91%

13. Learning Points
• Significant LAD occlusion with dynamic ECG changes can still have
negative high sensitivity troponins
• Don’t wait 12 hours for repeat ECG if any concerns
• Try to learn some features that suggest BEP:
– Widespread concave ST elevation ST
– Most commonly V2 – V5
– Notching is common at J point
– Rare > 50 years
– ST elevation is usually:
• less than 2mm in precordial leads (but can be more!)
• < 0.5mm in limb leads
– No reciprical ST segment changes
– Normal R wave progression
– Changes are relatively stable
• Download SubtleSTEMI and give it a try

15. PESIT TRIAL

16. PESIT
• Cross sectional multi-centre study
• All patients with 1st
episode syncope admitted
from ED
• All then got D dimer testing and Wells score
• Negative D dimer and PE unlikey wells score
 testing stopped
• +ve D dimer or PE likely Wells score  CTPA
or Ventilation Perfusion Scan

17. PESIT
• 2584 patients presented to ED with syncope
• 717 (27.7%) patients admitted
• Of these 157 excluded
• 560 patients included in study
• > 75% over 70 years old
• 58.9% had PE ruled out on Well’s score / D
dimer
• 17.3% had diagnosed PE

18. Clot Burden
– 41.7% Main Pulmonary artery
– 25% Lobar Artery
– 26.4% Segmental Artery
– 6.9% Subsegmental Artery

21. Discussion

22. Discussion
• 1/6 pick up rate of PE for syncope sounds high
• Remember that lots of people were sent home – so actually < 4% of
patients presenting with syncope to ED
• PE was much more likely if:
– Tachopnoea
– Tachycardiac
– Hypotensive
– Clinical signs of DVT
– Active cancer
• You would hope we would expect PE in syncope ?cause if any of these
features
• Did finding the PE also find the cause of syncope?
– 26% segmental, 7% subsegemental
– Much debate about the relevance of diagnosing these
• False +ve rate high
• clinical significance of diagnosis uncertain

23. References
• http://hqmeded-ecg.blogspot.com.au/2017/02/chest-
pain-st-elevation-and-negative.html
• http://lifeinthefastlane.com/ecg-library/benign-early-
repolarisation/
• http://www.emdocs.net/ber-vs-anterior-stemi/
• http://www.annemergmed.com/article/S0196-
0644(12)00160-6/pdf
• http://heart.bmj.com/content/94/12/1620.full
• http://sinaiem.org/clot-or-not-what-are-we-going-to-
do-about-pesit/