This page covers the ECG signs of myocardial ischaemia seen with non-ST-elevation acute coronary syndromes. ST-elevation / Q-wave myocardial infarction patterns are covered elsewhere (see links at bottom of page).
Non-ST-elevation acute coronary syndrome (NSTEACS) encompasses two main entities:
- Non-ST-elevation myocardial infarction (NSTEMI).
- Unstable angina (UA).
The differentiation between these two conditions is usually retrospective, based on the presence/absence of raised cardiac enzymes at 8-12 hours after the onset of chest pain. Both produce the same spectrum of ECG changes and symptoms and are managed identically in the Emergency Department.
Patterns of Myocardial Ischaemia
There are two main ECG abnormalities seen with NSTEACS:
While there are numerous conditions that may simulate myocardial ischaemia (e.g. left ventricular hypertrophy, digoxin effect), dynamic ST segment and T wave changes (i.e. different from baseline ECG or changing over time) are strongly suggestive of myocardial ischaemia.
Click on the links above to read more about the different causes of ST segment and T wave abnormalities.
Other ECG patterns of ischaemia
Morphology Of ST Depression
- ST depression can be either upsloping, downsloping, or horizontal (see diagram below).
- Horizontal or downsloping ST depression ≥ 0.5 mm at the J-point in ≥ 2 contiguous leads indicates myocardial ischaemia (according to the 2007 Task Force Criteria).
- ST depression ≥ 1 mm is more specific and conveys a worse prognosis.
- ST depression ≥ 2 mm in ≥ 3 leads is associated with a high probability of NSTEMI and predicts significant mortality (35% mortality at 30 days).
- Upsloping ST depression is non-specific for myocardial ischaemia.
ST segment morphology in myocardial ischaemia
Distribution of ST segment depression
ST depression due to myocardial ischaemia may be present in a variable number of leads and with variable morphology:
- ST depression due to subendocardial ischaemia is usually widespread — typically present in leads I, II, V4-6 and a variable number of additional leads.
- A pattern of widespread ST depression plus ST elevation in aVR > 1 mm is suggestive of left main coronary artery occlusion.
- ST depression localised to a particular territory (esp. inferior or high lateral leads only) is more likely to represent reciprocal change due to STEMI. The corresponding ST elevation may be subtle and difficult to see, but should be sought. This concept is discussed further here.
T wave inversion
T wave inversion may be considered to be evidence of myocardial ischaemia if:
- At least 1 mm deep
- Present in ≥ 2 continuous leads that have dominant R waves (R/S ratio > 1)
- Dynamic — not present on old ECG or changing over time
NB. T wave inversion is only significant if seen in leads with upright QRS complexes (dominant R waves). T wave inversion is a normal variant in leads III, aVR and V1.
- Wellens’ syndrome is a pattern of inverted or biphasic T waves in V2-4 (in patients presenting with ischaemic chest pain) that is highly specific for critical stenosis of the left anterior descending artery.
- Patients may be pain free by the time the ECG is taken and have normally or minimally elevated cardiac enzymes; however, they are at extremely high risk for extensive anterior wall MI within the next 2-3 weeks.
There are two patterns of T-wave abnormality in Wellens’ syndrome:
- Type 1 Wellens’ T-waves are deeply and symmetrically inverted
- Type 2 Wellens’ T-waves are biphasic, with the initial deflection positive and the terminal deflection negative
Wellens’ Type 1
Wellens’ Type 2
Read more about Wellens’ syndrome here.
Non-specific ST segment and T wave changes
The following changes may occur with myocardial ischaemia but are relatively non-specific:
- ST depression < 0.5 mm
- T wave inversion < 1 mm
- T wave flattening
- Upsloping ST depression
More ECG Examples
- The most striking abnormality is the widespread ST depression, seen in leads I, II and V5-6. This is consistent with widespread subendocardial ischaemia.
- There is also some subtle ST elevation in V1-2 and aVR with small Q waves in V1-2, suggesting that the cause of the widespread ischaemia is a proximal LAD occlusion.
- The most obvious abnormality is the horizontal ST depression in III and aVF.
- This could be misinterpreted as “inferior ischaemia” — however, subendocardial ischaemia does not localise.
- Regional ST depression should prompt you to scrutinise the ECG for signs of reciprocal ST elevation… In this case there is subtle ST elevation in aVL.
- This is a high lateral STEMI!
Dr Stephen Smith covers two similar cases on his excellent ECG blog.
- There are abnormal T waves in V1-4 — biphasic in V1-3 and inverted in V4.
- This pattern is known as Type 2 Wellens’ Syndrome and is highly specific for a critical stenosis of the proximal LAD artery.
Dynamic ST depression in a patient with chest pain:
- Widespread ST depression (leads I, II, V5-6) indicates subendocardial ischaemia.
- Q wave in lead III with slightly elevated ST segment suggests the possibility of early inferior STEMI.
ECG of the same patient after treatment with oxygen, nitrates, heparin and antiplatelets:
- The ST changes have now resolved.
- Inferior ST segments and Q waves are stable — this patient had a history of prior inferior MI.
- Troponin was raised, confirming that the initial ST depression was due to NSTEMI.
NSTEMI presenting with isolated U wave inversion:
- There are inverted U waves, most prominent in leads V5-6.
- This is an infrequently recognised but very specific sign of myocardial ischaemia — this patient had a 12-hour troponin of 4.0 ng/mL.
To find out the full story behind this ECG, click here.
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- Thompson, Peter L. Coronary Care Manual, 2nd edition. Elsevier, 2011.
- Thygesen K, Alpert JS, White HD; Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction. Universal definition of myocardial infarction. Eur Heart J. 2007 Oct;28(20):2525-38. PubMed PMID: 17951287. Full text.
- Wagner, GS. Marriott’s Practical Electrocardiography (11th edition), Lippincott Williams & Wilkins 2007.
- ECG BASICS — Waves, Intervals, Segments and Clinical Interpretation
- ECG A to Z by diagnosis –alphabetical diagnostic approach to the ECG
- ECG CLINICAL CASES — ECG’s placed in clinical context with a challenging Q&A approach
- 100 ECG Quiz — Self-assessment tool for examination practice
- ECG Reference SITES and BOOKS — the best of the rest
- LITFL ECG IMAGE Database — Searchable database of LITFL ECG’s
- ECG and Cardiology Eponymous Syndromes — Cheats guide to eponymous emancipation
- ECG Exam Template — a framework for answering ECG exam questions.