Wednesday, January 24, 2018

A 40-something male with epigastric pain

A 40-something male presented with epigastric pain.

An ECG was recorded immediately (time zero):
This was texted to me asking for my opinion.
What do you think?

My answer: Normal variant

He had serial ECGs:

This was recorded at t = 40 minutes:

Subsequently, the patient was diagnosed with cholecystitis.

This was recorded at t = 110 minutes

Notice there is some change from ECG to ECG, but this is not uncommon in these normal variants.

That you cannot entirely rely on the temporal stability of the ECG to diagnose normal variants is, to use a favorite phrase, "Sad!".

All serial troponins were below the level of detection.

Learning points

How does one recognize one such ECG as ischemic and one as normal variant?  Why are these not Wellens' waves?

All I can say is that you need to read many many ECGs and get experience and follow up on the outcomes of your interpretations!  There are many cases on this blog that can help you to recognize the difference.

ECGs are like faces: you can easily tell different person's faces from one another, even though they mostly have the same features: 2 eyes with eyebrows, a nose, cheeks, mouth and lips, etc.  How do you describe the difference?  And yet you know it because of your experience with seeing tens of thousands (or more!) of faces over a lifetime.

Unfortunately, doctors who spend a lifetime learning to recognize such patterns eventually retire or die, and all that knowledge is lost.

We are working to produce a Deep Neural Network ECG algorithm that will learn forever.  It is sad for experts that such a network may one day replace human expertise, but very good for patients.

Here are other examples of normal variants with T-wave inversion that look scary:

Persistent Juvenile T-wave Pattern

8 year-old with report of "syncope and an abnormal ECG"

Here are cases of normal variant ST elevation that looks scary:

High ST Elevation in a Patient with Acute Chest Pain

A 50-something year old with typical chest pain

Several Cases of ST Elevation from Early Repolarization


  1. Hi Dr.Smith,

    thank you for your great blog!

    I immediately saw the early repol pattern in V3 (s-wave and j-wave), but the inverted t-waves in the inferior leads and the missing early repol pattern in v1-v2 made me unsure if this is some ischemia superimposed on early repol.
    Is there a way to be sure that is not the case? What made you so sure it is just early repol? After all , the patient was having cp

    1. Thanks. Mostly because I recognize the pattern. It is difficult to say why. As I say in the post, so much is like recognizing a face.

    2. Thank you for your answer!

      I looked at the ecg again and i found that the QTc is rather long (480 if i measured correctly) and there appear to be some u-waves in V2-V5.
      In case my observations are correct : Is it possible that these changes are due to BER or is there maybe some hypokalemia?

    3. I measure the QT at just over 400. The computer measured 413. I think you're including the U-wave in your measurement? There was no hypokalemia. U-waves are normal in early repolarization!

  2. Wonderfully insightful case. I also thought ECG #1 was more likely to represent early repolarization — because: i) the totally rounded ST-T wave in lead V2, especially in context with the prominent J-point at the onset of the ST segment in lead V3 just “didn’t look like” a stemi pattern; ii) although there is ST elevation in lead aVL (and the opposite picture in the inferior leads) — the prominent J-point notching in lead aVL again just looks like early repolarization; iii) QRS amplitude is markedly increased in the anterior leads (with transition already by V1-to-V2) — whereas one typically expects diminished R wave progression when there is anterior stemi. That said, ample voltage for LVH is present in this 40yo man (R in V5>25; R in V6>20) — and the ST-T wave changes in lateral chest leads to me suggests LVH more than early repolarization …

    ECGs #2 and #3 show definite change compared to ECG #1. I would definitely be much more concerned if the ONLY ECG I saw in this patient was ECG #3. And although ST-T wave changes can vary even in patient with early repolarization — a repolarization variant with a variable pattern on serial tracings is clearly a diagnosis of exclusion. In addition, it is possible to have a “baseline” consisting of a repolarization variant + LVH, with an acute evolving event on top of that … That’s why it is so helpful in this case to be told of the follow-up from Dr. Smith that serial troponins remained below the detectable level — thus confirming (by exclusion) that no acute cardiac process was ongoing. THANKS for presenting this superb case!

    1. Ken..doesn't the t wave inversion pattern resembles apical cardiomyopathy ??

    2. @ AKS — Thanks for your question! As I suggested in my comment just above your question — “A repolarization variant with a variable pattern on serial tracings is clearly a diagnosis of exclusion”. Part of the process of exclusion (ie, to rule out underlying structural hearts disease, as per your question) would be getting an Echo.

  3. It looks a bit like LVH. Doesn't it?

    1. I can see why you say that, but this is a very specific morphology, a normal variant.

  4. Did you plan further non-invasive investigation for this patient? like CCTA?

    1. No. ECG is normal. EDACS score very low. All trops neg. Does not need further workup!


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