Monday, October 15, 2012

A Man in his 20's with Syncope. What is diagnosis? And what does the old ECG show?

A young man presented after a syncopal episode.  He felt fine in the ED.  He had no previous cardiac history, but stated that he does have an abnormal baseline ECG.

Here is his ED ECG:

There is a hyperacute T-wave in lead III which is far larger than a small QRS.  There is reciprocal ST depression and and inverted reciprocally hyperacute T-wave in lead aVL and I.  Precordial leads support the diagnosis of STEMI, showing posterior STEMI.

So this young person with syncope and no other symptoms is having a STEMI?

Could it be that this is his abnormal baseline ECG?


There is no baseline abnormality which looks like this.

There is a condition of baseline inferior ST elevation ("early repolarization" in the limb leads).  We have shown that this never has reciprocal ST depression.  Here is the reference:

Bischof J.  Thompson RP.  Tikkanen J.  Porthan K.  Huikuri H.  Salomaa V.  Smith SW.  ST-segment depression in lead aVL differentiates benign ST elevation from inferior Acute STEMI.  ACEP Research Forum 2012.  Annals of Emergency Medicine 60(4 Suppl):S8-S9; October 2012.

The patient was taken for PCI of 100% thrombotically occluded RCA.  The etiology of the syncope is uncertain, but probably some dysrhythmia related to the inferior STEMI.

Later, his baseline abnormal ECG was obtained.  Here it is.

This is classic "Benign T-wave Inversion"

To learn all about Benign T-wave Inversion, read this.


  1. Wow. At my community hospital I believe it would be an understatement to describe that as a "hard sell" to cardiology.

  2. Interesting!

    Do you have access to any further information? What causes a 20-year old to have total RCA occlusion? How was the outcome?

  3. Great case!

    Were any risk factors determined for his MI?

    What was the decision making process that landed this asymptomatic 20 year old int he cath lab (troponin, echo)?


  4. As I recall, there was a family history. It is important to remember that young people do have atherosclerosis and do get coronary thrombosis, too!

    Remember, too, that young women get MIs. They are systematically ignored and have higher mortality because they are undertreated. See this new article:

  5. They showed the ECG to an expert and he reassured them that this could only be a STEMI.

    1. Very nice. I always say that when the pt. and the test disagree, the test is wrong.
      But the EKG can't be thrown into the "non-specific" test category when there are specific findings. Wish II and F were more impressive, but I know I would have hemmed and hawed and wasted time on ths one.


DEAR READER: We welcome your Comments! Unfortunately — due to a recent marked increase in SPAM — we have had to restrict commenting to Users with a GOOGLE Account. If you do not yet have a Google account — it should not take long to register. Comments give US feedback on how well Dr. Smith’s ECG Blog is addressing your needs — and they help to clarify concepts of interest to all readers. THANK YOU for your continued support!

Recommended Resources