ST segment elevation


  • Its presence must be explained (there is no "nonspecific ST elevation")
  • Not specific only to STEMI

Clinical Features

  • Depends on underlying etiology

Differential Diagnosis

ST Elevation


Early Repolarization versus STEMI

  • Early Repolarization suggested by:
    • ST elevation <4mm
    • Notched J point
    • Concave or saddle-back ST morphology
    • No reciprocal changes
    • Consistent over short term
    • Young patient without risk factors

LVH versus STEMI

  • Difficult to exclude MI in patient with LVH (patients with LVH are already at risk for MI)
  • Best aid is prior ECG or serial ECGs


See Sgarbossa's Criteria


  • ST elevation in those leads that reflect the distribution of a single coronary artery
    • RCA: II, III, aVF (inferior)
    • LAD: V1-V4 (antero-septal)
    • Circumflex: V5-V6, I, aVL (lateral)
    • Dominant left circulation: infero-lateral
  • ST morphology
    • Concave up versus convex
      • Convex has Sp 97%, Sn 77%
  • Look for reciprocal ST depression
    • 35% of anterior STEMI have ST depression in inferior leads
    • 80% of inferior STEMI have ST depression in anterior leads
      • However, may represent reciprocal changes OR posterior STEMI

Reciprocal Changes

  1. Anterior STEMI
    • Reciprocal ST-segment depression in at least one of leads II, III, aVF
    • Occurs in 40-70% of cases
  2. Inferior STEMI
    • Reciprocal ST-segment depression usually present in I, aVL; often in V1-V3
    • Occurs in 56% of cases
  3. Posterior STEMI
    • Reciprocal ST-segment depression in V1-V4
      • Differentiate from inf STEMI reciprocal depression based on upright T waves, posterior leads showing STEMI
    • Often associated with ST-segment elevation in II, III, aVF (inferior involvement)

STEMI Stages of Development

Stage Duration Timing Finding ECG

30min - hoursHyperacute T waves
  • >6mm limb leads
  • >10mm precordial leads
Normalizes in days, weeks, or months

Minutes - hoursST segment elevation
  • 0.1mV in two or more contiguous leads
ST segment resolution occurs over 72hrs; completely resolves within 2-3wks

Within 1hr; completed within 8-12hrQ wavesPersist indefinitely in 70% of cases

See Also


  1. Gibbons RJ, Balady GJ, Bricker JT, Chaitman BR, Fletcher GF, Froelicher VF, Mark DB, McCallister BD, Mooss AN, O'Reilly MG, Winters WL Jr, Gibbons RJ, Antman EM, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Hiratzka LF, Jacobs AK, Russell RO, and Smith SC Jr. ACC/AHA 2002 guideline update for exercise testing: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). Circulation 2002 Oct 1; 106(14) 1883-92. pmid:12356646.
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