Sunday, February 14, 2016

Is it early repol, pericarditis, or anterior STEMI?

This was sent to me by a reader:

This patient was a 26y/o pulled over by Police when he complained of chest pain that radiated to left arm. EMS was called. The initial 12 lead is here:

Smith comment:
There is sinus tachycardia.  There is a high voltage QRS, particularly high voltage S-waves in V2 and V3.  There is marked ST elevation in V3-V5, but there are also very marked J-waves in those leads and the T-waves are not large relative to the QRS.
This is all highly suspicious for early repolarization, especially in a 26 year old.
One can use the LAD occlusion vs. early repolarization formula: I have magnified V1-V6 for better measurement:
STE at 60 ms after the J-point in lead V3 (STE60V3) = 4 mm, QTc = 386 ms, and R-wave amplitude in V4 (RAV4) = 16 mm, we get 22.342

A value of 22.342 strongly supports early repolarization (about 95% sensitive for LAD occlusion in all comers, but has a better negative predictive value in a 26 year old).

With this, I would do serial ECGs and an emergent echo to look for a wall motion abnormality.  I would not activate the cath lab, as LAD occlusion is very unlikely.  

Of course it is better to be safe than to miss an LAD occlusion, but a an echocardiogram done with contrast and interpreted by an expert will not miss an LAD occlusion and would spare the cath team a night time activation.

Crews became concerned about ACS and administered ASA, nitro, and serial ECG's showed no change in ECG.

The patient was taken to the cath lab upon arrival at hospital.

When I first saw this ECG I thought the elevation looked concerning but the QT was not that long and there is huge QRS in anterior and lateral leads. QRS in lead V4 is at least 15 according to my calculations give or take. I saw no reciprocal depression.

Pt went to the cath lab where his coronaries were found to be clean. Troponin's were not elevated. Cardio echo showed no wall motion abnormality and good function.  The patient was observed overnight and discharged the next day with diagnosis of pericarditis.


I doubt this was pericarditis.  Pericarditis has inferolateral ST elevation primarily.  This is classic early repolarization.


  1. What about LVH ? There is voltage criteria and probebly LAE as non voltage criteria.

    1. It meets LVH voltage criteria, but that does not mean there is true pathologic LVH. Many young men meet LVH criteria without actually having LVH. Especially athletes.

  2. Dr. Smith,
    I wonder if there is PR depression at II, III, aVF & V3-6 and reciprocal PR elevation at aVR, suggesting pericarditis, perhaps superimposing on early repolarisation?
    Many thanks!

    1. There is PR depression, but PR depression is not specific to pericarditis. Suggestive, but not diagnostic.

    2. See Ken Grauer's comment below.

  3. GREAT case that illustrates so many of the concepts you have so often emphasized regarding assessment of chest lead ST elevation. I interpreted the initial tracing identically as you did. I appreciate you magnifying the ECG and specifying the parameters you measured for entry into your formula. Only in this way can others ENSURE that they are interpreting your directions for using your formula in the same manner it is intended to be used.

    What I especially like about this case is your initial Gestalt interpretation with explanation for how the relatively short QTc, preserved R wave progression, J-point notching, lack of reciprocal changes, and dramatically increased overall amplitude all combine to make acute STEMI highly unlikely prior to applying your formula (which then supports this conclusion) — but that given the circumstances (ie, new-onset chest pain and ST elevation on ECG) — your approach to attain > 99% certainty that this isn’t acute is to do serial tracings + stat Echo. THAT approach is a MODEL for others to emulate! The cath lab does NOT have to be activated for a case like this one.

    Otherwise — I agree completely that this is NOT the ECG of a patient with acute pericarditis given the lack of limb lead ST elevation (as well as a pattern of chest lead ST elevation that looks so much more like early repolarization).

    THANKS for posting! — :)

  4. This is a very interesting case but first of all a very interesting ECG. I must admit that I would have been worried if I had seen this ECG and my first thought would have been that the patient has a STEMI (but of course in that case I would have used the LAD occlusion/Early-Rep formula and I would have expected some degree of wall motion abnormality on Echo). Actually I've never seen a BER with such an amount of STE (about 4 mm in V4!).
    According to you experience, are there some data on degree of STE in BER?

    Another aspect is the role of the automated interpretation of ECGs. It's true that it is very useful (I recall pre-hospital interpretation, the Qtc, among others) but in some cases it could affect the clinician's behaviour. In other words, in this specific case the automatd report says “MEET ST ELEVATION MI CRITERIA” and “CONSIDER ACUTE INFARCT ” and that could have some influence (negatively and/or positively) on what the clinician will do.
    If one misses STEMI, then someone could state:
    “Look at the ECG: even the machine tell you that this is an MI!” What is your opinion?
    Many thanks.

    Mario Parrinello

    1. Mario,
      I agree with all you say. Even though I would think, on initial viewing, that this is early repol, I would not stop my evaluation there because it is a disaster to be wrong. And those with less experience that I must be even more careful. So in my teachings, I teach to be careful! One must be nearly 100% accurate. So further diagnostic workup is necessary, but not angiogram.
      As for mm in early repol, it can be up to 5 mm.

  5. Any comment about initial straightening of T wave in V2,V3 ? could be early ischemia

    1. Mostafa,
      Normally, that would worry me. But not when there is so much S-wave voltage.
      Thanks for the insightful comment!

  6. Your blog is incredible! I have been looking through your posts on pericarditis and I get that there arent great hard and fast rules to make the diagnosis. I would love it if you could kindly have one post with all the best diagnostic criteria for pericarditis. Or, if you already have one, please reply with the link. Again, your expertise is invaluable. THank you.

    1. Thanks! I'll keep that in mind for future posts!


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