Chapter 15 Test — STEMI Equivalents and Mimics: Recognizing Patterns That Require Emergent Intervention

The two ECG patterns shown are both recognised forms of Wellens’ syndrome. Which statement about them is CORRECT?

A 55-year-old man is admitted after two days of intermittent chest pain that has now settled. He is currently pain-free with a normal troponin, but his resting ECG shows deeply inverted, symmetric T waves in leads V2–V3 with preserved R waves and no Q waves. This pattern is most characteristic of:

A 58-year-old woman is admitted with a history of chest pain that has now fully resolved. Her ECG shows biphasic T waves in V2–V3, no Q waves, and troponin is normal. Which of the following is the most dangerous next step?

A 47-year-old man has had crushing central chest pain for 40 minutes. His ECG shows the pattern illustrated in leads V1–V6, together with 1 mm ST elevation in aVR. There is no ST elevation in any precordial lead. The most likely diagnosis is:

The De Winter T-wave pattern is recognised in a patient with ongoing chest pain. What is the correct management?

A 52-year-old man presents with crushing central chest pain of 20 minutes’ duration. An ECG is obtained within 5 minutes of arrival and shows the appearance in V2–V3 illustrated here. Which ECG change appears FIRST in the evolution of an acute myocardial infarction?

Which feature BEST distinguishes the hyperacute T waves of early STEMI from the peaked T waves of hyperkalaemia?

A 58-year-old smoker presents with tight epigastric pain; he is sweaty and unwell. His ECG shows horizontal ST depression in V1–V3 with tall broad R waves (R greater than S in V2) and upright T waves in those leads. The most likely diagnosis is:

The recording shown includes three additional leads placed on the posterior chest wall. Regarding these leads, which statement is CORRECT?

A 60-year-old diabetic woman presents with acute chest pain. Her ECG shows ST elevation greater than 1 mm in lead aVR with widespread ST depression in the other leads. The likely site of thrombosis is:

A 66-year-old man with ongoing chest pain has 1.5 mm ST elevation in aVR with 2 mm ST depression in leads I, II, V3, V4, V5 and V6. Haemodynamics are stable. What is the most appropriate management?

A 64-year-old diabetic man presents with vague chest discomfort and diaphoresis for 2 hours. BP is 92/60 mmHg, HR 108/min. His ECG shows QRS duration 150 ms, a QS complex in V1–V2, absence of septal Q waves in I and V6, and broad notched M-shaped R waves in V5–V6. An ECG from 3 months ago was normal. What is the correct management?

A patient with known, old LBBB presents with chest pain. Applying the original Sgarbossa criteria, which finding carries the greatest weight (5 points)?

How do the modified (Smith) Sgarbossa criteria differ from the original criteria?

A 68-year-old woman develops severe chest pain an hour after her husband’s funeral. Her ECG is shown and demonstrates anterior precordial ST elevation. Troponin is only mildly raised. What is the most appropriate immediate management?

A 35-year-old woman develops chest pain after acute emotional stress. Imaging shows transient myocardial stunning with apical ballooning, and her coronary angiogram is normal. The most likely diagnosis is:

Consider these statements about Takotsubo cardiomyopathy:
1. There is acute right ventricular dysfunction with dilatation of the right ventricular apex.
2. It can be precipitated by acute emotional stress and is frequently associated with an underlying neuro-psychiatric disorder.
3. Symptoms and ECG findings often mimic acute ST-elevation myocardial infarction.
4. Ventriculography shows a normal left ventricle with apical ballooning of the right ventricle.
Which statements are correct?

Which single feature is MOST useful in distinguishing acute pericarditis from an acute STEMI on the ECG?

A 22-year-old asymptomatic man has this ECG recorded as part of a pre-employment check. There is concave ST elevation with notching at the J point in the inferolateral leads, no reciprocal changes, and an identical ECG from two years ago. The most likely explanation is:

All of the following may cause ST-segment elevation on the ECG EXCEPT:

When assessing an ECG with ST elevation, which combination MOST strongly favours a true STEMI over a mimic, according to the chapter’s four-question approach?