what does “evolving EKG” mean?

An “evolving EKG” is often mentioned for a patient suffering from acute coronary syndrome (UA, NSTEMI, or STEMI). As the term implies, EKGs change over time in a patient with at-risk or actively infarcting tissue. You should monitor EKGs and be able to answer the following questions:

  • does the patient have pain at the time the EKG was taken?
  • did the patient improve with nitroglycerin or another intervention at the time the EKG was taken?

Knowing the answers to those questions will give you a clue about the severity and type of event the patient is having.

This is the typical progression of wave changes you can expect to see on the EKG:

  1. TWI
  2. ST depressions
  3. “straightening” of ST segments
  4. ST elevations
  5. Q waves once the infarct is completed
  6. ST elevations in the setting of Q waves of old infarct are not as impressive as this could just be the tissue stretching over areas of old scar.
  7. A “stuttering course” of a STEMI may at times look like an NSTEMI, but it’s just the natural progression of the course. That’s because in a STEMI, you may see spontaneous reperfusion (plaque rupture) that causes the ST elevations to be hidden. But then you get additional vasospasm that may increase ST elevations.

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