ST segment elevation is observed during transmural ischemia.

  Coronary spasm causing transmural myocardial ischemia may also result in ST segment elevation.

  Persistence of myocardial ischemia more than 20 minutes initiates myocardial necrosis.

      Therefore ST segment elevation is seen not only in myocardial ischemia but also in the first hours of

      myocardial infarction.




Causes of ST segment elevation

  Early repolarization

  Acute myocardial infarction

  Prinzmetal angina (coronary vasospasm)

  Left bundle branch block (LBBB)

  Left ventricular hypertrophy

  Pericarditis

  Left ventricular aneurysm

  Brugada syndrome





ECG 1. The ECG above belongs to a healthy young man. The
ST segment elevation is due to early repolarization.
The concavity of the
elevated ST segment looks upward. There is no accompanying reciprocal ST segment depression.

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ECG 2.
Upwardly concave ST segment elevation in a patient with acute pericarditis.

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ECG 3a. This patient was diagnosed as acute anterior myocardial infarction because of
ST segment elevation in anterior leads .
The concavity of the ischemic ST elevation looks downwards. This patient also has accompanying
reciprocal ST segment
depression
.

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ECG 3b. While preparing to start intravenous thrombolytic therapy, sublingual nitroglycerin was administered to the patient.
In a few minutes, the chest pain disappeared. Ten minutes after nitroglycerin, ST segment elevation was not seen anymore.

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ECG 4a. Ischemic
ST segment elevation in the inferior leads during typical chest pain in a patient with coronary artery disease.

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ECG 4b. After 15 minutes the chest pain disappeared. ECG shows no ST segment elevation.

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ECG 5. Generally, ST segment elevation less than 1 mm does not suggest coronary stenosis.
The ECG above shows
ST segment elevation in inferior leads . He has no coronary artery stenosis.

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ECG 6a. This ECG was recorded just before the treadmill exercise test. There is no ST segment abnormality in this pretest ECG.

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ECG 6b. The ECG after 2 minutes and 50 seconds of exercise shows
ST segment elevation in the inferior leads .

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ECG 6c. In the recovery period (20 seconds after stopping treadmill), the ECG still shows
ST segment elevation in inferior leads .
Persistence of ST segment elevation in the recovery period suggests significant coronary stenosis.

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ECG 6d. The ECG above was recorded 2 minutes and 20 seconds after the ending of exercise.
There is no ST segment elevation in the inferior leads.

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Figure 1. Later on, this patient underwent coronary angiography which
revealed
99% stenosis in the right coronary artery (RCA) .




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