Pre-course: The 12-Lead ECG and Acute Myocardial Infarction: Improving Your Interpretation Skills

Sunday 2 October: 8:30 - 12:30

Course Director

  • Jerry W. Jones

Maximum number of delegates that can be accommodated:  20

Objective of the course 

The objectives of the pre-course are:

1. To be able to recognize subtle changes in the 12-lead ECG that are highly suggestive of acute ischemic episodes or actual myocardial infarction (ST deviation in aVR, inverted U waves, axis shifts)

2. To understand the difference between “reciprocal changes” and “ischemia at a distance”

3. To improve the recognition of “STEMI-equivalents”

4. To learn why some acute MIs are not always visible on the 12-lead ECG: cancellation of forces, electrically silent areas

5. To increase familiarity with new revelations regarding the true location of infarcting areas and the complexities of the vascular supply to the various areas of the heart

6. To increase knowledge of certain conduction disturbances that are classically associated with particular infarctions

7. Becoming more familiar with acute MI confounders: left ventricular hypertrophy, early repolarization, Takotsubo cardiomyopathy

Content of the course

The content will include didactic as well as audio-visual presentations. In keeping with my company’s philosophy of active participation by those in attendance, there will be actual ECGs that the participants themselves will take turns interpreting during the class while I assist and guide them. There will be handouts containing copies of ECGs (all identifying data redacted) and copies of lecture notes. There will also be copies of a few pertinent journal articles.

For a four-hour pre-course, the content will be divided thus:

First Hour – Discussion of the actual position of the heart in the chest and recent revelations regarding the locations of some of the “classical” infarction locations (“posterior” is now “lateral” or “posterolateral” and “anteroseptal” is now “anteroapical”) will start the pre-course. We will begin the discussion of specific acute myocardial infarctions with a closer look at acute inferior MIs: which vessels cause inferior MIs, how to distinguish between inferior MIs caused by the RCA, LCx or the LAD, the problem of acute inferior MIs with ST depression in the precordial leads, acute inferior MIs and cancellation of forces and the problem of acute inferior MIs with ST elevation in the precordial leads. Conduction disturbances commonly associated with acute inferior MIs will also be presented.

Second Hour – This hour is devoted to problems diagnosing ischemia in the distribution of the left circumflex artery: the reason for “invisible” MIs, the various presentations of a left circumflex occlusion and the peculiarities of the blood supply to the high lateral and lateral left ventricular walls as opposed to the septal and anterior surfaces. Confounders of acute (and old) myocardial infarctions will be introduced: LVH, early repolarization, Takotsubo cardiomyopathy, LV aneurysm, ventricular pre-excitation and normal variant findings.

Third Hour – Discussion of types 1, 2 and 3 left anterior descending arteries, the importance of recognition of proximal and distal occlusions of the LAD and how the LAD can affect the presentation of occlusions in the other coronary arteries will begin the third hour. We will also devote some time to the recognition of acute myocardial infarctions in the presence of left bundle branch block. The recognition of subtle harbingers of proximal LAD occlusion will also be presented. We will also discuss the role of Lead aVR in the recognition of left main, very proximal LAD and three-vessel disease.

Fourth Hour – The fourth hour will be devoted to the interpretation of real ECGs with the active involvement of all the participants. Concepts presented during the first three hours will be reinforced and new “tips, tricks and pearls” will also be introduced.