A man in his 30s with epigastric pain and chest pressure

Written by Pendell Meyers

A man in his 30s presented with acute upper midline abdominal pain and nausea. He described it as radiating into his chest, like "pressure", and "burning". 

Vitals were within normal limits except bradycardia. Here is his triage ECG:

What do you think?

Sinus bradycardia, normal QRS. There is STE in several leads including I, aVL, and V2, with STD in II and aVF. The question is whether this is due to OMI, or not. If it were due to OMI, it would fulfill the "South African Flag" pattern.

Unfortunately, presence of reciprocal depression does not ensure that STE is due to OMI. 

I sent this ECG with zero other information to Dr. Smith and Dr. Frick, both said it was an OMI mimic (meaning they do not think that the STE in I, aVL, V2, etc, is due to acute coronary occlusion, but rather a normal variant). I agreed, there is something about the morphology (including the J waves, but not limited to that) that doesn't match prior OMIs in my experience, and does match prior normal variants. 

PM Cardio QOH says No signs of OMI.

The ECG meets STEMI criteria objectively.

The ED physician did not think the ECG represented OMI.

Two serial high sensitivity troponin T levels were undetectably low (less than 6ng/L). AMI was ruled out.

One other ECG was obtained during the ED stay:

The patient was discharged home. No further follow up is available.

Compare this case with similar OMIs and OMI mimics:

Quiz post - which of these, if any, are OMI? What is the South African Flag Sign? Will you activate the cath lab? Can you tell the difference on ECG?

Quiz post: do either or both of these patients have high lateral OMI / South African flag sign?

Abdominal Pain in a middle-aged patient

True Positive ST elevation in aVL vs. False Positive ST elevation in aVL

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MY Comment, by KEN GRAUER, MD (2/14/2025):

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I find cases like today's challenging. My answers usually take 1 of 3 forms: i) That the initial ECG is diagnostic or strongly suspicious of acute OMI until proven otherwise; — ii) That the initial ECG is simply not suggestive of anything acute; — or — iii) That I do not think the initial ECG represents an acute OMI — but I would not send the patient home on the basis of this single ECG.

• For me, today's initial tracing best fits in Category iii) — in that I did not think this tracing represents an acute OMI — but that I would want more information before sending the patient home.

For clarity in Figure-1 — I've labeled today's initial ECG to highlight the findings that "caught my eye".

Figure-1: I've labeled the initial ECG in today's case.

Today's Initial ECG:

For an otherwise presumably healthy 30-year old man — there are some unusual findings in ECG #1. These include the following:

• A fairly marked sinus arrhythmia with bradycardia, and almost the pattern of "group" beating in the long lead rhythm strip. P wave amplitude is reduced in virtually all leads — with comparable small size of the upright P waves in lead I as in lead II, making me question whether this truly is a sinus rhythm? — vs a low atrial rhythm? — vs the possibility of LA-LL Reversal? (See My Comment in the June 25, 2024 post for changes with LA-LL reversal). The above said — this is not necessarily an abnormal rhythm in a young adult.
• A 4-component rSR's' complex in lead V1. This is not a simple incomplete RBBB pattern, which should only consist of 3 components without a terminal s' deflection.
• A slender, but unusually deep Q wave in lead III (that is over 5 mm deep). Narrow Q waves are also seen in leads aVF and V6.
• Prominent J-point notching in leads I and aVL. These look a bit unusual, because we are not accustomed to seeing such deep S waves in these high-lateral leads. That said — this notching is usually a benign feature of repolarization variants, especially when associated with no more than modest ST elevation associated with an upward concavity (ie, "smiley" configuration), as seen here.
• From the perspective of a patient presenting to the ED with abdominal pain radiating to the chest — I found the flat (shelf-like) ST depression in lead aVF to be the most concerning feature in this tracing.
• J-point depression with a downsloping ST segment and biphasic T wave in lead III would have added to my concern if this ST-T wave picture in lead III was not the exact mirror-image opposite of what I perceived to be a benign picture of prominent J-point with smooth, upsloping ST elevation in lead aVL.
• Finally, though not more than minimally depressed — the flattened ST segment in lead V6 could be complementary to the ST depression seen in lead III.

Putting It All Together: 

I thought the initial ECG in today's case was not "normal" for a man in his 30s.

• I did not think this initial tracing represented an acute OMI — because of the benign-looking appearance of J-point notching with upward sloping ST elevation in leads I,aVL.
• I wondered if some of the unusual QRS features in the limb leads could be the result of LA-LL reversal — so I would verify lead placement.
• That said — a form of limb lead reversal would not alter the 4-component rSR's' complex in lead V1, so the leads may be correctly placed.
• I'd want to know about the patient's body habitus (as possible explanation for some of the less usual ECG features).
• And then, I am left with that shelf-like ST segment depression in lead aVF — that is not usually part of the picture of a repolarization variant. And this patient did present to an ED with new symptoms of a "pressure" that radiates to the chest. Primarily for this reason — I was less than 100% certain about the diagnosis.
• BOTTOM LINE: I did not think ECG #1 represented an acute OMI. That said — I was less than 100% certain of that on the basis of the single initial ECG. As a result — I would: i) Repeat the ECG after verifying lead placement; — ii) Rule out acute OMI with 2 serial Troponins, as was done; — and, iii) Get an Echo to rule out any unexpected underlying structural disease (I find it insightful to always try to better understand why a non-OMI ECG may have unexpected features).