DSAE STEMI Review, Mod 2: Another Comparison of ST-elevation – BNV & Acute Anterolateral STEMI

In this section we will present the discussion and comparison of Early Repolarization (Benign Normal Variant) versus Acute Anterolateral STEMI by referring to two tracings as follows:

Early Repolarization Example…

Now Acute Anterolateral STEMI….

Benign Normal Variant (Early Repolarization)

During your daily practice of medicine, you are frequently faced with the following scenario:

You are presented with a cardiogram which demonstrates minor, subtle ST-segment elevations concave up.  After analyzing the tracing, you have narrowed your choices to:

  1.  Benign Normal Variant (Early Repolarization).
  2.  Early, suspected Acute STEMI.

The sobering ramifications of this decision-making are obvious.  On the surface this challenge might appear to be straightforward, but in the clinical world you will encounter tracings that challenge even the most expert eye.

General comments regarding Early Repolarization Pattern

  • Serial tracings will show essentially no changes evolving (unless an infarction is evolving also)
  • Early Repolarization patterns essentially never show “terminal QRS distortion” (further discussion below)

Let us now review two serial tracings of an Acute Anterolateral STEMI – tracing “A” and tracing “B” at 1.5 hours.

TRACING A:  The tracing below represents the initial presenting cardiogram of a 32 year old with ACS.

The tracing below is a serial tracing of the same patient at 1.5 hours later…


I want you to focus on two aspects of these tracings:

  1.  The low point (nadir) of the S-wave of Leads V1, V2, V3
  2. The terminal R-wave of Leads V4, V5, V6

FINDINGS SUGGESTIVE OF ACUTE ANTERIOR STEMI (as opposed to benign normal variant)

  • ST-segment elevation, concave down (tombstoning, plateauing; sometimes concave up) in Leads V1 to V4 (maximum Leads V2, V3)
  • ST-segment depression of reciprocity (especially in Leads II, III, avF, V5, V6)
  • Poor R-wave progression
  • Anterior Q-waves present
  • Late transition
  • Presence of Hyperacute Ts
  • Terminal QRS distortion

Please be aware that sometimes the ST-segment elevation is concave up (even in the setting of the acute STEMI).  In these cases it is especially important to carefully look at all the clues, especially the “terminal QRS distortion”.

The next section to follow is a discussion of the phenomena of terminal QRS distortion and it’s role in analyzing the ST segment of the ECG.