Tuesday, December 31, 2013

Hyperacute T-waves? Anterior STEMI? No, LVH with PseudoSTEMI pattern!

A woman in her 30's with h/o HTN presented with atypical chest pain after a stressful event.  Here is her ED ECG:
There is sinus tachycardia.  There are very large anterior T-waves, with ST elevation.  However, there is also very high voltage.  Criteria for LVH is clearly reached in aVL, with tyical repolarization ("strain") in aVL.  The ST elevation and tall T-waves are discordant to deep S-waves in V2 and V3.

I took care of this patient and was concerned about the ST-T waves in V2 and V3, but thought that they were almost certainly a result of LVH.  One should not apply the LAD occlusion vs. Benign Early Repol Formula if the patient has LVH.  Had I done so, with a QTc of 375ms, the formula value would have been 26.1, indicating anterior STEMI.  Here is another example of LVH resulting in a falsely positive formula value.

I think that the formula would be more accurate if it took into account the entire QRS, not just the R-wave.  I will be using all the original ECGs to study this hypothesis.

There were no previous ECGs for comparison.

We did a bedside cardiac echo which showed concentric LVH and a well functioning anterior wall.  A repeat ECG 30 minutes later was identical.  We recommended admission for further evaluation but the patient signed out against medical advice.

Her heart rate came down with IV fluids.

I am quite certain that this is the patient's baseline ECG.


1. LVH can result in PseudoSTEMI patterns of various morphologies.  Here are some others.
2. The formula may give false positives in LVH

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