Wolff-Parkinson-White (WPW) – STEMI Mimic

A really interesting 12-Lead ECG was posted to the Cardiology & Electrocardiography (ECG, EKG) Experts group on Facebook the other day.

If you’re not familiar, this is one of the groups / fan pages on Facebook I help moderate with Jason Winter who also started the Cardiology & Electrocardiography Experts blog.

What’s so interesting about this ECG is that it shows a relatively infrequent STEMI mimic. In addition, it helps demonstrate a point I’ve been pondering about several of the STEMI mimics in general.

Let’s take a look.



The patient was a 29 year old male with no complaints. The ECG was captured during a routine workup according to the contributor Chris de Beer (thanks again for the interesting ECG, Chris).

The ECG shows a WPW pattern as evidenced by a short PR interval and delta waves. The delta waves create a pseudo-infarct pattern (Q-waves) in the septal leads.

You might recall from my previous post about left ventricular hypertrophy (LVH) that I think recognizing the so-called “strain pattern” is actually more important than knowing the “voltage criteria” for LVH.

I’m sure some of you are waiting for “Part II” of the left ventricular hypertrophy series, but I’m still waiting for inspiration! :)

What does this ECG have in common with a strain pattern from left ventricular hypertrophy (LVH)? What does it have in common with left bundle branch block (LBBB)? What does it have in common with ventricular rhythms? Including paced rhythms?

The answer is, it has a widened QRS-T angle! To put it another way, the T-waves and ST-segments are deflected opposite the main deflection of the QRS complex, and (this point is the most critical) the degree of the ST-T abnormality is proportional to the size of the QRS complex.

Think of this as a supplement to Sgarbossa’s criteria and the “rule of appropriate T-wave (and ST-segment) discordance”.

Here’s a graphic to help illustrate the point.



When you see a pattern like this, regardless of cause, it should set off alarm bells that you are dealing with a STE-mimic and not acute STEMI!

Note that the S-wave in lead V3 is cut off by the bottom of the ECG paper. This is a common problem with prehospital 12-lead ECGs! We must presume that the S-wave would be the deepest in lead V3 if we were able to view the entire QRS complex.

That doesn’t mean the patient isn’t experiencing acute myocardial infarction (although this patient is asymptomatic so let’s pretend he was over the age of 30 and complaining of chest discomfort).

It just means you should wait before pulling the trigger on the cardiac cath lab.

Look for changes on serially obtained ECGs instead!

2 Comments

  • Jesse says:

    So not to blog jump my questions on you, but..Youve stated elsewhere that an accessory pathway (such as WPW) can be indicated by polymorphic QRS complexes, (which Im guessing is a by product of the different conduction locations of the pathway and AV node?)and an R-R interval of 240 ms.If you dont mind answering.. How specific of a finding is this? And while I can speculate the reasons these criteria exist, Im curious of the actual etiologies behind them.Thank you!

  • Tom B says:

    Jesse – Keep in mind that there's a difference between the WPW pattern on the 12-lead ECG (like this one, a short PR-interval and delta waves) and the WPW Syndrome, which involves various tachycardias that are enabled by the presence of an accessory pathway.Atrial fibrillation in the presence of an accessory pathway can be quite dangerous. That's the polymorphic rhythm where the shortest R-R interval of 240 ms or less indicates an increased danger of VF.The other tachycardias you might hear about are the orthodromic reciprocating tachycardia (down the AV-node and up the accessory pathway) which is generally a narrow complex rhythm, and the antidromic reciprocating tachycarida (down the accessory pathway and up the AV-node) which is generally a wide complex tachycardia.These tachycardias are sometimes referred to as AVRT (AV-reentrant tachycardias) as opposed to AVNRT (AV-nodal reentrant tachycardias) which do not involve an accessory pathway.At least, that's my limited understanding! You can learn more by Googling these terms.Thanks for commenting!Tom

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EMS 12-Lead

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation

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Comments
know it all parapup
83 Year Old Male: Shortness of Breath
@ Kyle I would question your authority to call out people for not having a license or being a know it all parapup when your tx basically entails "call medical control." I think we can both agree that his cardiac output is not great at all. I assume your reluctance to give him any other…
2014-10-30 20:26:11
Kyle
83 Year Old Male: Shortness of Breath
Well st elevation in avr and v1 associated with anterior and lateral depression would call for possible posterior wall MI. 15 lead would be in order. Also check all the leads for appropriate placing. If v7, v8, and v9 show the elevation i would treat as a STEMI per my protocol. Asprin only until medical…
2014-10-30 18:14:05
Tim
The most awesome STEMI test on the internet!
Thanks for the app. It made me think about all that one may see in the field. The only problem was I never got a score or saw the results of how I did other than saying I had completed the test. Anyway a great way to get the old brain working.
2014-10-30 13:14:27
Brian
83 Year Old Male: Shortness of Breath
I mostly agree with dustin. I believe this is may be an isolated posterior MI. The R wave in V2 points to it being a posterior MI. otherwise it is a 1st degree av block with a LAHB. I am somewhat concerned with the concordant t segment depression noted and in fact if you were…
2014-10-30 04:22:44
Karl Brennan
Understanding Amiodarone
Great article , however in VF caused by hyperkalemia it should be avoided along with lidocaine , Since it shuts down the K channels, the eiteiology of the arrest hyper K, K channels are needed to exchange K in the cell. Calcium , Bicarbonate, dextrose and insulin should be used to decrease K levels along…
2014-10-30 03:04:45

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