ECG
Use the J-point for measurement in 2 contiguous leads
J point is the junction between the end of the QRS complex and the beginning of the ST<unk> 
When possible, compare to old ECGs
Repeating ECGs will increase sensitivity
CBC
Chem 7
Troponin
PT/PTT
Consider CXR
Use the J-point for measurement in 2 contiguous leads
J point is the junction between the end of the QRS complex and the beginning of the ST<unk> 
When possible, compare to old ECGs
Repeating ECGs will increase sensitivity
J point is the junction between the end of the QRS complex and the beginning of the ST<unk> 
Look for ST<unk>  elevation, reciprocal ST depression, and hyperacute T waves
Men
In males  ≥ 40 years old 2mm in V2-V3 and 1mm in all other leads
In males  < 40 years old  2.5mm in V2-V3 and 1mm in all other leads
Women
≥1.5 mm in V2-V3 and 1 mm (0.1mV) in all other leads
In males  ≥ 40 years old 2mm in V2-V3 and 1mm in all other leads
In males  < 40 years old  2.5mm in V2-V3 and 1mm in all other leads
≥1.5 mm in V2-V3 and 1 mm (0.1mV) in all other leads
Up to 10% of<unk> s; usually associated with inferior MI
≥0.5 mm<unk> s diagnostic
Look at V1-V3
Large R waves (posterior Q waves)
STD
Upright T waves
Large R waves (posterior Q waves)
STD
Upright T waves
Get immediate ECG after arrest<unk> : go to cath lab immediately (AHA/ACCF Class IB)<unk> : go to cath within 2 hrs if VT/VF, intractable ischemic pain, ADCHF (AHA/ACC Class IA)
New LBBB alone is no longer<unk>  criteria for cath lab as of 2013 per ACC/AHA guidelines
Hemodynamically unstable or new HF pts with new LBBB should be discussed with a cardiologist for PCI or fibrinolytics
≥3 points = 98% probability of<unk> 
ST elevation ≥1 mm in a lead with upward (concordant) QRS complex - 5 points
ST depression ≥1 mm in lead V1, V2, or V3 - 3 points
ST elevation ≥5 mm in a lead with downward (discordant) QRS complex - 2 points
Least specific of criteria, see Smith's modification
ST elevation ≥1 mm in a lead with upward (concordant) QRS complex - 5 points
ST depression ≥1 mm in lead V1, V2, or V3 - 3 points
ST elevation ≥5 mm in a lead with downward (discordant) QRS complex - 2 points
Least specific of criteria, see Smith's modification
Least specific of criteria, see Smith's modification
Changes the 3rd rule of original Sgarbossa's Criteria to be ST depression OR elevation discordant with the QRS complex and with a magnitude of at least 25% of the QRS increases Sn from 52% to 91% at the expense of reducing Sp from 98% to 90%
Pacemakers in AMI
Sgarbossa criteria can be applied to paced rhythms
Low sensitivity but high specificity
DeWinter T-waves
High risk of ACUTE (vs subacute in Wellen's) anterior MI (proximal LAD occlusions)
Look for 1-3 mm STD at J-point in mid precordial leads with tall symmetric T waves
ST elevation in aVR
Reflects subendocardial ischemia in LV (L main vs multi vessal disease)
Look for STE >1-1.5 mm in aVR
Can also bee seen in hemorrhage, type A Dissection, massive PE
Aslanger criteria
Aslanger pattern is a reliable sign of acute inferior MI, indicating occlusion of the RCA or left circumflex artery
Defined by a pattern consists of 3 criteria:
ST elevation in leads III and aVRbut not in any other inferior lead
ST depression in any of leads V4to V6but not in V2, AND
ST in lead V1 higher than ST in lead V2.
Leads III and aVR are contiguous in anatomical position; therefore, they should be recognized as contiguous leads on ECG.
Sgarbossa criteria can be applied to paced rhythms
Low sensitivity but high specificity
High risk of ACUTE (vs subacute in Wellen's) anterior MI (proximal LAD occlusions)
Look for 1-3 mm STD at J-point in mid precordial leads with tall symmetric T waves
Reflects subendocardial ischemia in LV (L main vs multi vessal disease)
Look for STE >1-1.5 mm in aVR
Can also bee seen in hemorrhage, type A Dissection, massive PE
Aslanger pattern is a reliable sign of acute inferior MI, indicating occlusion of the RCA or left circumflex artery
Defined by a pattern consists of 3 criteria:
ST elevation in leads III and aVRbut not in any other inferior lead
ST depression in any of leads V4to V6but not in V2, AND
ST in lead V1 higher than ST in lead V2.
Leads III and aVR are contiguous in anatomical position; therefore, they should be recognized as contiguous leads on ECG.
ST-segment elevation myocardial infarction
Cardiac
Non-ST-elevation myocardial infarction
ST-segment elevation myocardial infarction 
Unstable angina
Post-MI 
Acute coronary syndrome 
Previous MI with recurrent ischemia in same area