Posts Tagged ‘non specific st segment’

This is the Incidental ECG of an apparently healthy 50-year-old businessman, recorded while  applying for health insurance

How will you describe this ECG?

Let me magnify it for you 

Why this big fuss about this ECG?

 Such ECGs are so common. Looking at the ST segment, we are supposed to think of significant CAD,, LVH, Aortic stenosis or variants of cardiomyopathy, and sometimes electrolytic shifts. The fact that it is recorded at rest, and the patient is absolutely asymptomatic, it is very unlikely there is ongoing ischemia.It could be a myocardial origin or an unknown repolarisation pattern. But, one thing is clear, we can’t send this guy under the label of non-specific ST/T changes.

The Echo was done it was normal. No WMA,  LVH. The aortic valve was perfect. 

Is CAG indicated here?

Three responses came from three different cardiologists. Everyone agreed, the stress test is not going to be useful, as  baseline  is unstable

  1. Absolutely not Indicated, since he is asymptomatic. I believe the history and Echo. Please follow him up
  2. A definite yes for CAG. (Being a scientific cardiologist, without excluding CAD, I can’t be at peace. Will do at least a CT angiogram)
  3. A third cardiologist said a CT angiogram is waste of time and wanted to do a radial CAG in 10 minutes in his newly opened hi-fi radial lounge.

What happened then?

Don’t know, whether he underwent CAG or not.  But, I can confidently say he will have a normal coronary angiogram.  How can you be so confident?  Confidence doesn’t mean I am correct. Look at the ST segment again. It is not true ischemic depression. It is neither non-sustained nor horizontal or downsloping*, This could be referred to as, primary T inversion with secondary ST segment dragging. Regarding the management,  the first response is ideal,

*Classical slope should begin at J point. Late downsloping has little predictive value as in this ECG.

Is Echo good enough to rule out structural heart disease?

Even after the echo was reported normal, few questioned the quality of the echocardiogram and asked to look specifically for apical wall motion with speckle track and GLS. ( I know, MRI is a must nowadays to rule out structural heart disease as Echo can’t rule out intrinsic myocardial disarray, infiltration, etc)

How is ST dragging different from ST depression?

                                                                Classical horizontal ST depression

Final message

The purpose of posting this ECG is, some ST segments create disproportionate panic than it deserves. The concept of  T waves pulling down the distal part of the ST segment which can be called ST segment dragging is being proposed here.

Some provocation for advanced readers 

Re-exploring the foundations of electro-cardiology is always welcome. Worth diving deep into mysterious terminology non-specific ST/T changes. ST  segment in the ECG  corresponds to the most stressful period since it represents the active part of mechanical contraction. Curiously, it Includes the entire electrical (Repolarisation) & most parts of mechanical relaxation. The true onset of LV myocardial mechanical relaxation we can’t be sure, It happens somewhere in late phase 2. I think it’s so difficult to decode that timing. But, what we can presume is ST segment behavior in its distal half is less specific for both ischemic as well as hemodynamic stress

The electro-mechanical continuity within the ST segment is so intimate, and the demarcation point between them is invisible in many clinical situations.   No surprise, we are largely in the dark about the true influence of the ST segment over T wave morphology and vice versa. (ie distal ST depression pulling down the T wave )  Though chronologically T must follow the S in timing,  it would seem impossible for “T” to go back in time and pull the ST down. (If QRS can precede P in a junctional rhythm, why not T do the same for ST? )  I am not sure whether there is any timing involved in antegrade vs retrograde repolarisation across endo-epicardial repolarisation dissociation.Further, we know very well, myocardial scars cause fragmented depolarisation in QRS. Can anyone guess effect of these scars in repolarisation vectors? (Fragmented ST segment ?)  I think it is worth pursuing this phenomenon. Let the young new age Sodipellares’ look into this.

Though the traditional rule of thumb, makes ST segment shifts more sinister, T-wave changes are largely benign, It is not an easy job to segregate benign from more serious forms of T-wave changes. Isolated new onset T inversion, can be an equally troublesome marker, especially mid-chest leads in the male population. 

It is interesting to note, not every T wave Inversion is empowered to drag the ST segment down. We don’t know why. It is something to do with the curvature of the shoulder zone of phase 2 /3 of the action potential. In this context, ST dragging could be an important concept to explore. 


. An example of isolated T inversion without influencing the ST segment. Try to compare this ECG with the one that is shown to drag the ST segment

Diastolic T wave stress

One more issue, which we are not yet clear is the timing of 2nd sound with reference to the T wave. It is a fact, a significant part of the T-wave will represent early diastolic hemodynamic stress* as well. 






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Often general practitioners refer  ECGs  with abnormal resting  ST/T wave patterns  to cardiologists .

Following are few of them

  • ST elevation
  • ST depression
  • T wave inversion
  • Tall T waves
  • A relatively uncommon  finding is  a flat ST segment  , which  is discussed here.

The commonest( benign) abnormality   is  T wave inversion  in women and tall ST /T waves   reflecting  early repolarisation  pattern in men. A flat ST segment is an occasional finding in general population.

ST segment is inscribed  during the most important  time  of  cardiac cycle.This is the period the ventricle is doing its prime function , namely ejecting the blood in systole .Hence it is subjected to maximum stress . During times of ischemia  ST segment  gets elevated or depressed depending upon the severity of ischemia. For the same reason , even  subtle changes in this segment is  frowned upon by cardiologists. Most of them would receive a EST.

It is ironical to note  , few normal people  show almost silent electrical activity during this  crucial  phase of   their  ECG .ST segment is often  a flat line  in them . This is a ECG of a women referred as CAD. She was asymptomatic . Echocardiogram  was normal . She was asked to do  a EST.

This asymptomatic women was refered for ECG opinion

The peculiar thing about T waves  are ,   a 10 mm upright  as well as  5 mm inverted T wave ,  both can be normal. So .  there is no element of surprise  to note absent  T waves  or a flat  T wave  to be called as normal .

The curious case of lost ST segment !

* T waves are recorded when K+ efflux occur rapidly out of cells . Hypokalemia  can be an important cause of flat T waves.

It is still a  mystery to me  why some people inscribe a tall T when  potassium comes out  of cell and  an equal number (Esp women)  record a down ward T wave  for the same event !  I wish  I get an answer  to this  lingering  question from  any of the readers !

Is a flat T wave represent  a T wave in  transition  to become inverted T wave  later ?

Possible .But we  are not sure ! A static T wave is safer than a dynamic T wave .

Final message

Flat ST segment and absent T waves  represent a same spectrum of ECG  findings  which  are  referred to as  non specific ST segment changes in  clinical practice .Generally , they have  little clinical significance.* In our experience we have found , female patients, Anemia  hypothyroidism  are  often associated with flat ST segments  . If CAD is suspected exercise stress test  should be done. Some believe a flat ST segment  is more likely to  result in EST positivity (Not necessarily true positive !)

* Non specific ST/T changes by itself is a  huge topic.  Ideally the term non specific ST /T changes should be avoided , as it  primarily came into vogue  to denote non ischemic ST segment (Still , other pathologies are very much  possible) It is estimated there are about  50 causes for non specific ST/T changes , right from a  benign situation  like deep   respirations , to significant  myocardial disorders. However , it still makes   good clinical sense for a  general practitioner  , to refer to a cardiologist , whenever ST  segment deviates  without any reason .

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