Annales françaises de médecine d'urgence

, Volume 1, Issue 6, pp 408–414

Syndrome coronaire aigu et ECG: les équivalents ST+

Mise au Point / Update

Résumé

La classification actuelle des syndromes coronaires aigus (SCA) et le traitement qui en découle reposent en grande partie sur l’ECG. Cette classification est paradoxale, car elle range des ECG avec sus-décalage de ST (ST+) dans le groupe des SCA non ST+ et des ECG sans sus-décalage de ST dans le groupe des SCA ST+. Elle est remise en question, car elle conduit à une stratégie invasive le plus souvent inutile dans le cas d’un « nouveau ou présumé nouveau bloc de branche gauche » et retarde l’heure de la désobstruction coronaire dans le cas de certaines anomalies ECG à risque d’évolution défavorable à court terme. Cinq entités ECG méritent d’être appelées équivalent ST+ en raison de leur pronostic défavorable: (a) un sous-décalage isolé de ST de V1 à V3(V4), (b) un bloc de branche gauche avec perte de la discordance appropriée, (c) un complexe ST/T de de Winter, (d) un sous-décalage de ST > 1 mm étendu aux dérivations antérieures, et (e) un sus-décalage de ST atypique. Bien qu’aucune recommandation aussi formelle n’existe à ce jour, nous proposons qu’en cas d’équivalent ST+ a ou b, la prise en charge soit immédiate, comme celle d’un SCA ST+ et qu’en cas d’équivalent ST+ c, d ou e, la prise en charge soit débutée sur place, puis rapidement poursuivie en milieu cardiologique où sera décidée l’heure de la stratégie invasive.

Mots clés

Syndrome coronaire aigu Infarctus Électrocardiogramme Diagnostic 

Acute coronary syndrome and ECG: the STE-equivalents

Abstract

The current classification of acute coronary syndromes (ACS) and the resulting treatment are largely based on the ECG. This classification is paradoxical because it ranks the ECG without ST-segment elevation (STE) in the group of ACS with STE and ECG with STE in the group of ACS without STE. It is questionable as it leads to an invasive strategy most often useless in the case of a “new or presumed new left bundle branch block” and delays the time of coronary desobstruction in the case of ECG patterns at risk of short term poor outcome. Five ECG patterns, deserve to be called STE-equivalent: (a) an isolated ST depression from V1 to V3(V4), (b) a left bundle branch block with loss of appropriate discordance, (c) a ST/T complex of de Winter, (d) a ST depression > 1 mm extended in anterior leads, and (e) an atypical ST elevation. Although no recommendations as formal exist to date, we propose that in case of equivalent-ST+ a or b, the management be immediate, like a ACS with STE, and that in case of equivalent ST+ c, d and e, the management be started on site then quickly continued into a cardiology center where will be decided the time of the invasive strategy.

Keywords

Acute coronary syndrome Infarction Electrocardiogram Diagnosis 

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Copyright information

© Société française de médecine d'urgence and Springer-Verlag France 2011

Authors and Affiliations

  1. 1.Service des urgences, hôpital Saint-LouisAssistence Publique — Hôpitaux de ParisParisFrance

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