Difficult ECGs in STEMI:: Lessons learned from serial sampling of pre- and in-hospital ECGs

Prehospital interpretation of electrocardiograms (ECGs) is crucial to ensure early diagnosis and optimal treatment of patients with ST elevation myocardial infarction (STEMI). Recognition of ST-segment elevations (STE) by qualified personnel in the prehospital phase has successfully reduced the delay from the first medical contact to reperfusion. A few other ECG patterns without true STE, referred to as “STEMI equivalents”, bear the same prognostic significance, reflect imminent or ongoing transmural ischemia, but are less easily identified. Hyperacute T waves, de Winter ST-T complex, Wellens' syndrome, and posterior STEMI, as well as myocardial infarction in the presence of left bundle branch block, paced rhythm or left ventricular hypertrophy, among others are diagnostic challenges. This article reviews some critical examples of ischemic ECG patterns that may be ephemeral, misinterpreted by medical staff or not identified by automated ECG algorithms, and it emphasizes the importance of serial ECG acquisition.