An ST elevation is considered significant if the vertical distance inside the ECG trace and the baseline at a point 0.04 seconds after the J-point is at least 0.1 mV (usually representing 1 mm or 1 small square) in a limb lead or 0.2 mV (2 mm or 2 small squares) in a precordial lead. The baseline is either the PR interval or the TP interval. This measure has a false positive rate of 15-20% (which is slightly higher in women than men) and a false negative rate of 20-30%.
The ST segment corresponds to a period of ventricular contraction. Because of the complete depolarization of the ventricles, represented by the QRS complex, in theory there is no net movement of charge during the ST segment. Under physiological conditions the ST segment is isoelectric (i.e. same charge across the myocardium).
During transmural (subepicardial) ischemia, the injured cells are "relatively" closer to the epicardial surface. In the case of depolarization, healthier cells will typically displace a larger amplitude and duration of depolarization. During systole, a ventricle with subepicardial ischemia will exhibit cells with higher amplitude of depolarization in the cardiac endocardium. During transmural ischemia, the Na+/K+ATPase which is responsible for the final stages of myocyte repolarization (-80mV to -90mV) is impaired; thus, the ischemic cells will only be partially repolarised compared to surrounding healthy (non-ischemic) myocytes. The difference in membrane potential between healthy and ischemic cells causes negative charges to accumulate on their surfaces, generating a vector that points towards the normal cardiac cells (which have positive charges on their surface). This vector points away from the chest EKG leads, causing a downward deflection in the TP segment. However, since the TP segment is the baseline of the EKG, the machine corrects for this by raising TP to baseline which results in ST elevation. Also see ST depression.
Repolarization of the ventricle normally occurs during the T wave, however one cause of ST segment elevation is the early repolarization of the heart wall. This is referred to as benign early repolarization.
The exact topology and distribution of the affected areas depend on the underlying condition. Thus, ST elevation may be present on all or some leads of ECG.
It can be associated with:
- Myocardial infarction (see also ECG in myocardial infarction). ST elevation in select leads is more common with MI. ST elevation only occurs in full thickness infarction
- Prinzmetal's angina
- Acute pericarditis ST elevation in all leads is more common with acute pericarditis.
- Left ventricular aneurysm
- Blunt trauma to the chest resulting in a cardiac contusion
- Acute myocarditis
- Pulmonary embolism
- Brugada syndrome
- J-point elevation
- Early repolarization
- Subarachnoid Hemorrhage
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