Tuesday, September 4, 2012

Male in his 40's with chest pressure: what is the diagnosis

This 40-some year old patient complained of chest pressure and had this ECG recorded:

See comments and diagnosis below

The providers were a bit worried about this ST elevation and I was in the department, so they showed it to me: my answer took 2 seconds and was unequivocal: LVH and early repolarization, no STEMI.

How did I know this?  Primarily because:

If inferior MI, there would be significant ST depression in aVL.
If anterior MI, there would not be such high voltage, especially in lead V4.

Though the early repol/anterior STEMI formula may give false positives in LVH (I'm actually not sure of this), the value obtained after plugging in STE60V3 = 5 mm, QTc = 400 ms, and R wave V4 = 33 mm = 18.2 (far less than 23.4, strongly arguing against anterior STEMI).  I did not use the formula, but one could do so and be reassured.

My colleagues appropriately did a bedside ultrasound and found completely normal function.  They did admit him for "rule out" and all troponins were negative.

Diagnosis: Anterior and "inferior" ST elevation due to LVH and early repolarization

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