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.

Lesson:

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

Recommended Resources