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Chest Pain & ECG

This is a valuable resource for recognizing different ECG diagnoses in the setting of chest pain.

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Conventional STEMI

STEMI is defined by the ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction as:

  • New ST Elevation at the J point in V2-3 of at least two contiguous leads

    • ≥2mm in men

    • ≥1.5mm in women

  • New ST Elevation in the J point of at least 1mm in two contiguous leads (except for V2-3)

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STEMI Equivalents

  • Chest Pain with New Onset Left Bundle Branch Block (LBBB)

  • Posterior MI

  • Sgarbossa Criteria

New Onset LBBB

  • QRS prolongation >120 ms

  • Abnormally appearing QRS complex

  • Leads V1-V3 will have deep S waves

  • Leads V5-V6 will have tall R waves

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Posterior STEMI

  • ST Depression >0.05 mV in V1-V3

  • Tall R in V1/V2 with R/S ratio >1 in V2

  • ST Elevation in Leads V7-V9 (Posterior Leads)

Sgarbossa's Criteria
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Sgarbossa criteria used to diagnose a STEMI in the context of LBBB on ECG. In the past, a new LBBB in a patient with ischemic chest pain was considered to be an indication for a patient to undergo cardiac catheterization. However, in recent years this has become more controversial with evidence suggesting these patients may be managed more conservatively

High Risk ECGs

  • Wellen's Sign

  • DeWinter's Sign

  • Hyperacute T-wave

  • Dynamic ST Changes

  • Diffuse ST Depressions with ST Elevation in aVR

Wellen's Sign
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DeWinter's Sign
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De Winter’s sign:

  • Sign of an occlusion of the left anterior descending artery

  • Upsloping ST depression greater than 1mm in the precordial leads

  • Prominent, tall, and symmetrical T waves in the precoridal leads

  • Absence of ST elevation in the precordial leads

  • Reciprocal ST elevation of 0.5mm-1mm in AVR

Hyperacute T-wave
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Diffuse ST Depressions with ST Elevation in aVR
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Other Noteworthy ECGs
Pericarditis
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ECG changes suggestive of Pericarditis:

  • Diffuse ST-segment elevations

  • PR depressions, best seen in II and V6

  • ST Depression in lead AVR with PR elevation

Acute Pulmonary Embolism
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ECG changes suggestive of P.E.:

  • Sinus tachycardia

  • S1Q3T3 pattern

  • T wave inversion in V1–V4

  • RBBB

Cardiac Tamponade
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ECG changes suggestive of Tamponade.:

  • Low voltage QRS

  • Electrical alternans

  • Nonspecific ST-T changes

 

© 2025 by JCS Chest Pain Care. 

Created  by JCS Chest pain Care Taskforce

Website Design by Kais Al Balbissi, MD, FACC, FSCAI.

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