{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T16:33:37Z","timestamp":1787762017439,"version":"build-2784847793"},"reference-count":21,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"1","license":[{"start":{"date-parts":[[2025,1,1]],"date-time":"2025-01-01T00:00:00Z","timestamp":1735689600000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc-sa\/4.0"}],"content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":[],"published-print":{"date-parts":[[2025,1]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>This review considers high-risk electrocardiographic patterns in the acute coronary syndrome (ACS) patient; we review 7 electrocardiogram presentations lacking diagnostic criteria for ST-segment elevation myocardial infarction (STEMI) yet likely representing either STEMI equivalent syndromes or ACS presentations with significant short-and long-term risk. The STEMI equivalent presentations include acute posterior wall myocardial infarction, the hyperacute T-wave of early STEMI, de Winter syndrome, first diagonal of the left anterior descending artery occlusion, and left bundle branch block modified Sgarbossa positive findings. High-risk presentation, not felt to be STEMI equivalent entities yet still possessing significant risk of short-and long-term adverse outcome, include lead aVR ST-segment elevation and Wellens syndrome. The features of each presentation, highlighting the electrocardiographic abnormalities, are presented and discussed.<\/jats:p>","DOI":"10.4103\/tjem.tjem_150_24","type":"journal-article","created":{"date-parts":[[2025,1,2]],"date-time":"2025-01-02T14:00:30Z","timestamp":1735826430000},"page":"1-9","update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":1,"title":["High-risk electrocardiogram presentations in the acute coronary syndrome patient \u2013 Beyond ST-segment elevation myocardial infarction"],"prefix":"10.4103","volume":"25","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3030-5521","authenticated-orcid":false,"given":"William J","family":"Brady","sequence":"first","affiliation":[{"name":"Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6614-2592","authenticated-orcid":false,"given":"Andrew E.","family":"Muck","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5336-9782","authenticated-orcid":false,"given":"James H","family":"Moak","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","published-online":{"date-parts":[[2025,1,2]]},"reference":[{"key":"R1-20250106","doi-asserted-by":"crossref","first-page":"2231","DOI":"10.1016\/j.jacc.2018.08.1038","article-title":"Fourth universal definition of myocardial infarction (2018)","volume":"72","author":"Thygesen","year":"2018","journal-title":"J Am Coll Cardiol"},{"key":"R2-20250106","doi-asserted-by":"crossref","first-page":"1925","DOI":"10.1016\/j.jacc.2022.08.750","article-title":"2022 ACC expert consensus decision pathway on the evaluation and disposition of acute chest pain in the emergency department: A report of the American College of Cardiology Solution Set Oversight Committee","volume":"80","author":"Writing","year":"2022","journal-title":"J Am Coll Cardiol"},{"key":"R3-20250106","doi-asserted-by":"crossref","first-page":"766","DOI":"10.1016\/j.annemergmed.2012.07.119","article-title":"Diagnosis of ST-elevation myocardial infarction in the presence of left bundle branch block with the ST-elevation to S-wave ratio in a modified Sgarbossa rule","volume":"60","author":"Smith","year":"2012","journal-title":"Ann Emerg Med"},{"key":"R4-20250106","doi-asserted-by":"crossref","first-page":"517","DOI":"10.1016\/j.annemergmed.2021.03.036","article-title":"Electrocardiographic diagnosis of acute coronary occlusion myocardial infarction in ventricular paced rhythm using the modified Sgarbossa criteria","volume":"78","author":"Dodd","year":"2021","journal-title":"Ann Emerg Med"},{"key":"R5-20250106","doi-asserted-by":"crossref","first-page":"409","DOI":"10.1016\/S0735-6757(98)90143-7","article-title":"Acute posterior wall myocardial infarction: Electrocardiographic manifestations","volume":"16","author":"Brady","year":"1998","journal-title":"Am J Emerg Med"},{"key":"R6-20250106","doi-asserted-by":"crossref","first-page":"448","DOI":"10.1016\/j.jelectrocard.2014.03.010","article-title":"Difficult ECGs in STEMI: Lessons learned from serial sampling of pre- and in-hospital ECGs","volume":"47","author":"Ayer","year":"2014","journal-title":"J Electrocardiol"},{"key":"R7-20250106","doi-asserted-by":"crossref","first-page":"15","DOI":"10.1136\/emj.2010.099861","article-title":"Posterior myocardial infarction: Are we failing to diagnose this?","volume":"29","author":"Khan","year":"2012","journal-title":"Emerg Med J"},{"key":"R8-20250106","first-page":"371","article-title":"Clinical characteristics and reperfusion times among patients with an isolated posterior myocardial infarction","volume":"25","author":"Waldo","year":"2013","journal-title":"J Invasive Cardiol"},{"key":"R9-20250106","doi-asserted-by":"crossref","first-page":"2071","DOI":"10.1056\/NEJMc0804737","article-title":"Interventional Cardiology Group of the Academic Medical Center. A new ECG sign of proximal LAD occlusion","volume":"359","author":"de Winter","year":"2008","journal-title":"N Engl J Med"},{"key":"R10-20250106","doi-asserted-by":"crossref","first-page":"1701","DOI":"10.1136\/hrt.2009.174557","article-title":"Persistent precordial \u201chyperacute\u201d T-waves signify proximal left anterior descending artery occlusion","volume":"95","author":"Verouden","year":"2009","journal-title":"Heart"},{"key":"R11-20250106","doi-asserted-by":"crossref","first-page":"8.e5","DOI":"10.1016\/j.ajem.2013.09.037","article-title":"A new ST-segment elevation myocardial infarction equivalent pattern? Prominent T wave and J-point depression in the precordial leads associated with ST-segment elevation in lead aVr","volume":"32","author":"Goebel","year":"2014","journal-title":"Am J Emerg Med"},{"key":"R12-20250106","doi-asserted-by":"crossref","first-page":"1326.e3","DOI":"10.1016\/j.ajem.2015.02.008","article-title":"Acute first diagonal artery occlusion: A characteristic pattern of ST elevation in noncontiguous leads","volume":"33","author":"Durant","year":"2015","journal-title":"Am J Emerg Med"},{"key":"R13-20250106","doi-asserted-by":"crossref","first-page":"481","DOI":"10.1056\/NEJM199602223340801","article-title":"Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block. 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ST segment elevation in lead aVR with less ST segment elevation in lead V(1)","volume":"38","author":"Yamaji","year":"2001","journal-title":"J Am Coll Cardiol"},{"key":"R15-20250106","first-page":"128","article-title":"Value of lead aVR in the detection of significant left main coronary artery stenosis in acute coronary syndrome","volume":"62","author":"Rostoff","year":"2005","journal-title":"Kardiol Pol"},{"key":"R16-20250106","doi-asserted-by":"crossref","first-page":"1366","DOI":"10.1016\/j.amjcard.2005.01.085","article-title":"Predictors of left main or three-vessel disease in patients who have acute coronary syndromes with non-ST-segment elevation","volume":"95","author":"Kosuge","year":"2005","journal-title":"Am J Cardiol"},{"key":"R17-20250106","doi-asserted-by":"crossref","first-page":"814","DOI":"10.1161\/01.CIR.0000084553.92734.83","article-title":"Prognostic value of lead aVR in patients with a first non-ST-segment elevation acute myocardial infarction","volume":"108","author":"Barrab\u00e9s","year":"2003","journal-title":"Circulation"},{"key":"R18-20250106","doi-asserted-by":"crossref","first-page":"334","DOI":"10.1016\/j.amjcard.2005.08.049","article-title":"Combined prognostic utility of ST segment in lead aVR and troponin T on admission in non-ST-segment elevation acute coronary syndromes","volume":"97","author":"Kosuge","year":"2006","journal-title":"Am J Cardiol"},{"key":"R19-20250106","doi-asserted-by":"crossref","first-page":"730","DOI":"10.1016\/0002-8703(82)90480-X","article-title":"Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction","volume":"103","author":"de Zwaan","year":"1982","journal-title":"Am Heart J"},{"key":"R20-20250106","doi-asserted-by":"crossref","first-page":"657","DOI":"10.1016\/0002-8703(89)90742-4","article-title":"Angiographic and clinical characteristics of patients with unstable angina showing an ECG pattern indicating critical narrowing of the proximal LAD coronary artery","volume":"117","author":"de Zwaan","year":"1989","journal-title":"Am Heart J"},{"key":"R21-20250106","doi-asserted-by":"crossref","first-page":"638","DOI":"10.1053\/ajem.2002.34800","article-title":"Electrocardiographic manifestations of Wellens' syndrome","volume":"20","author":"Rhinehardt","year":"2002","journal-title":"Am J Emerg Med"}],"container-title":["Turkish Journal of Emergency Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.ovid.com\/10.4103\/tjem.tjem_150_24","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T16:11:48Z","timestamp":1787760708000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.ovid.com\/10.4103\/tjem.tjem_150_24"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,1]]},"references-count":21,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2025]]}},"URL":"https:\/\/doi.org\/10.4103\/tjem.tjem_150_24","relation":{},"ISSN":["2452-2473","2452-2473"],"issn-type":[{"value":"2452-2473","type":"print"},{"value":"2452-2473","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,1]]},"assertion":[{"value":"2024-08-04","name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2024-10-24","name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}}]}}