Monday, June 10, 2013

4 mm of ST elevation in lead V2 (at the J-point) relative to PQ junction

A male in his 30's male complained of chest pain  while having a dental procedure, then became syncopal.  The patient is young and healthy, and thin.  He had no past medical history.  In the ED, he felt and looked fine, with normal vital signs and no chest pain.

Sinus rhythm.  High voltage.  The computerized QTc is 390 ms.  There is 4 mm of ST elevation in lead V2, and 1.5 mm in V3 (at J-point, relative to PQ junction).  There are straight ST segments in V2 and V3, which suggest STEMI.  However, the voltage is very high and the QT is relatively short.  

In this case, the ST elevation does meet the standard STEMI  "criteria" (see below) because there is 1 mm in V1 and 4 mm in V2, even though there is only 1.5 mm in V3.

Strictly speaking, the early repol vs. anterior STEMI formula should not be used because the ST segments are non-concave (i.e., straight, though not upwardly convex).  Nevertheless, if it is used, the result is 17.4, which is very low.

From reference 1: At least 2 Consecutive Leads With ST elevation of:

V1, V4-V6: 1 mm
V2, V3: for men over 40 yo: 2 mm
for men under 40 yo: 2.5 mm
for women, any age: 1.5 mm

A repeat ECG 2 hours later was unchanged.  The patient was discharged.

Diagnosis: Early repolarization with high voltage in young healthy patient with a thin chest wall.  Syncope due to vasovagal event (neurocardiogenic syncope) in dentist's chair.

1. Wagner GS, Macfarlane P, Wellens H, et al. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part VI: acute ischemia/infarction: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society. Endorsed by the International Society for Computerized  Electrocardiology. J Am Coll Cardiol. 2009;53:1003-1011.


  1. In this case there is little uncertainty to an experienced eye that this is early reporalisation. If any doubt, however, a standard echo would confirm that in the absense of any regional wall motion abnormalities.

  2. When I first look at it, The elevation seems more proportional to the deep S wave secondary to LVH. I would think Bi-ventricular Hypertrophy. Also, the T waves are asymmetrical. Also another finding aiming towards RVH is RV strain in lead III. I would have considered ER after chamber enlargement. Either way, great case. Thank you

  3. I presume the troponin came back negative before the patient was discharged?
    Peter Hammarlund

    1. I didn't even check it, as I recall. Absence of any change in the ECG at 2 hours was enough to reassure that the ECG was not STEMI, and the patient's clinical presentation was enough to assure me it was a vasovagal event.

      Steve Smith

  4. what about this case dr smith

    1. Interesting case, but completely different. My case has very large QRS voltage.
      steve smith

  5. Hey Dr Smith, I think you meant 1.5mm STE in V3 rather than V2.


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