Click here for cases of early repolarization vs. LAD occlusion.
A 35 yo woman had the sudden onset of epigastric pain, more severe and different from her usual acid-related pain. She presented ambulatory. She had an ECG ordered by the triage nurse. The patient and the ECG were placed in a far-away room.
The computerized ECG read was:
"Minimal ST depression, inferior leads" and
"ST Elev, Probable normal early repolarization pattern."
This ECG is diagnostic of STEMI: the T-waves in V2 and V3 tower over the entire QRS. As described in 3 previous cases, inferior ST depression is due to high lateral STEMI (see this post and this post):
Early repolarization always has prominent R-waves in V2-V4. This is not early repol.
Because of a variety of issues, the physician did not see this ECG immediately. Had the computer read "ischemia" or "AMI", the tech would have brought it immediately to his attention. He did not rush to see it because it was a 35 year old woman with atypical symptoms. When he did see it, he recognized STEMI immediately.
The next ECG showed anterior Q-waves. She did go to the cath lab with some delay and had an ostial LAD occlusion that was opened. She had a subsequent EF of 35%!
- Anyone, of any age or sex can have MI.
- Do not trust the computer.
- You must read the ECG yourself.
- Have a system to review all ECGs that have been recorded.
Earlier posts on early repolarization use the application of a regression equation to differentiate early repol from anterior STEMI. See this post (which also includes an example of serial ECGs, this post (which also demonstrates straightening of the ST segment, and this post (which also shows serial ECGs improving after a reperfused LAD occlusion).
Below is an old rule. It is best now to use the equation on the sidebar:
I have also derived a simpler rule but which may not work as well in cases of very low or very high QTc:
If 2 of 3 of these are positive, then it is anterior STEMI over early repol with a sensitivity and specificity of 90%:
1) R-wave in V4 less than 13 mm
2) computerized QTc greater than 392 ms
3) ST elevation at 60 ms after the J-point greater than 2 mm
Here is another example that points out the use of serial ECGs when the diagnosis is in question: