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Myocardial Infarction and Ischemia: ECG changes

In this course, we define the term ‘acute coronary syndrome’. We explain the role and limitations of the ECG in the diagnosis of this syndrome. We expand your knowledge of the differential diagnosis of ST segment elevation and depression on the ECG.

2.0 x AMA PRA Category 1 Credits™
Available on the Pro Plan



In this course, we define the term ‘acute coronary syndrome’ and explain the role and limitations of the ECG in the diagnosis of this syndrome. We explain the difference in pathological processes underlying ST elevation MI (STEMI) and non-ST elevation MI (NSTEMI). We describe the time-dependent sequence of changes in ECG abnormalities resulting from complete occlusion of a coronary artery. We explain the origin of Q waves in STEMI. We show you how to identify the likely site of complete coronary artery occlusion in an STEMI based on analysis of ECG findings.  We test your ability to identify the ECG changes of acute coronary syndrome. A frontline worker must also appreciate that the ECG changes usually associated with ischemic heart disease have an extensive differential. Building on your understanding of the ECG changes described in the videos, we expand your knowledge of the differential diagnosis of ST segment elevation and ST segment depression on the ECG in the Essential Reading List.


Planner and Author: Dr John Seery MB PhD

  • Consultant Physician at St. Vincent's University Hospital, Dublin, Ireland
  • Lecturer at the School of Medicine and Medical Science, University College Dublin, Ireland
  • Studied medicine at the University of Cambridge, United Kingdom
  • A Natural Sciences graduate of Trinity College Dublin, Ireland
  • PhD in Cell Biology from University College London, United Kingdom

Planner: Dr Karen Strahan PhD (University of Cambridge), Head of Editorial
Planner: Tommy O'Sullivan, CME Manager

Estimated Time to Complete

2.0 hours

Target Audience

  • Physicians
  • Nurses
  • Nurse Practitioners
  • Physician Assistants
  • Paramedics

Learning Objectives

Upon successful completion of this activity, you will be able to:

  • Define the term ‘acute coronary syndrome‘
  • Describe the pathogenesis of STEMI and NSTEMI
  • Explain the origin of ST elevation in complete coronary artery occlusion 
  • Know how to identify the time-dependent ECG manifestations of complete coronary artery occlusion
  • Know how to identify the anatomical site of arterial occlusion in STEMI by analysis of the ECG
  • Identify the ECG changes of NSTEMI
  • Know how to Identify reciprocal change on the ECG in the presence of STEMI
  • Know when to consider an expanded differential in a patient presenting with chest pain syndrome associated with ECG abnormalities and an elevated troponin

Course Content

  • Introduction
  • Acute Coronary Syndromes
  • ST Elevation Myocardial Infarction
  • STEMI - Localization
  • NSTEMI & Unstable Angina
  • Quiz
  • Quiz Explanation
  • Essential Reading

Release date


Expiration date


Instructions for Participation

Participants must complete the online activity during the valid period as noted above.
Follow these steps:

  1. View videos in sequence
  2. Read the papers on the essential reading list
  3. Complete the quiz
  4. View post quiz video to support learning outcomes and objectives
  5. Complete the activity evaluation form to provide feedback for continuing education purposes and for the development of future activities
  6. Download the Certificate of Completion

Relevant Financial Disclosures

Acadoodle adheres to the ACCME's Standards for Integrity and Independence in Accredited Continuing Education. Any individuals in a position to control the content of a CE activity, including faculty, planners, reviewers or others are required to disclose all relevant financial relationships with ineligible entities (commercial interests). All relevant conflicts of interest have been mitigated prior to the commencement of the activity.

Planners and faculty for this activity have no relevant financial relationships with commercial interests to disclose.


Birnbaum Y and Drew BJ. The electrocardiogram in ST elevation acute myocardial infarction: correlation with coronary anatomy and prognosis. Postgrad Med J. 2003;79:490-504.

de Blieck EC. ST elevation: Differential diagnosis and caveats. A comprehensive review to help distinguish ST elevation myocardial infarction from nonischemic etiologies of ST elevation. Turk J Emerg Med. 2018;18(1):1-10.

Tewelde SZ et al. Pitfalls in Electrocardiographic Diagnosis of Acute Coronary syndrome in Low-Risk Chest Pain. West J Emerg Med. 2017; 18(4):601-6.

Brady WJ and Morris F. Electrocardiographic ST segment elevation in adults with chest pain. J Acad Emerg Med. 1999;16:433-9.

Wagner GS et al. AHA/ACCF/HRS Recommendations for the Standardization and Interpretation of the Electrocardiogram. Part VI: Acute Ischemia/Infarction: A Scientific Statement From the American Heart Association Electrocardiography and Arrhythmias Committee, Council of Clinical Cardiology, the American College of Cardiology Foundation; and the Heart Rhythm Society: Endorsed by the International Society for Computerized Electrocardiology. Circulation. 2009;119(10):e262-e270.

Additional Reading

Frankenfeld L. STEMI in Disguise. Taming the SRU:Emergency Medicine Tamed. 2019

Walsh L. Diagnostics: MI in Left Bundle Branch Block. Taming the SRU:Emergency Medicine Tamed. 2019

Di Diego JM and Antzelevitch C. Acute Myocardial Ischemia: Cellular Mechanisms underlying ST segment Elevation. J Electrocardiol. 2014;47(4):486-90.

Rossello X et al. New Electrocardiographic Criteria to Differentiate Acute Pericarditis and Myocardial Infarction. Am J Med. 2014;127:233-9.

ACCME Accreditation Statement

Acadoodle, Ltd is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit Designation Statement

AMA Physician’s Recognition Award

Acadoodle, Ltd designates this enduring material activity for a maximum of 2.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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