Monday, October 8, 2018

Hyperacute T-waves and Concordant ST Elevation seen in PVCs only

This comes from Steffen Grautoff, who is an Emergency Physician and Cardiologist who works on the Emergency Vehicles in the Northwest of Germany.

Steffen writes this case:

"A few weeks ago I was able to recognize a STEMI because of what I had seen on your blog."

"I have enclosed the ECG from a 50-something year old male who complained of chest pain. I was on scene at his working place (in Germany physicians are on the Emergency vehicles). Surprisingly enough he had undertaken a tour on the bike just two days ago without any complaints." 

"He had no further risk factors for atherosclerosis besides hypertension. However, I was a little unsure on scene whether it was a problem of his coronaries." 

"But when I took a look at the 12 lead-ECG I got a big smile on my face, because I remembered the ECG from your blog."

These are recorded at 50 mm/sec:

What do you think?

Here I have compressed them so they look as if they are recorded at 25 mm/sec.  I also put them side by side:
What do you think?

Steffen wrote:

"I remembered the ECG from your blog titled: "STEMI Seen Best in PVC, Diagnosed by Medic, Ignored by Physician" from 2013. The ECG looked similar (although at paper speed 50 mm/s) and – no surprise - an LAD occlusion was found in cath."

What is Steffen referring to?

Look in leads V2 and V3.  The PVC has a RBBB configuration (qR or rSR') because it originates in the left ventricle.  The ST segment in RBBB should be in the opposite direction to the terminal R'-wave.  That is, the ST segment should be somewhat depressed.  But it is elevated, concordant to the R'-wave.  This is a very specific sign of OMI (Acute Anterior MI due to LAD occlusion).

Notice also that the PVCs in V4-V6 have hyperacute T-waves that are much more pronounced than the only moderately hyperacute T-waves of the normal beats.  In fact, of the normal beats, only V4 shows a clearly hyperacute T-wave.

There are also Hyperacute T-waves in the PVCs in the limb leads.

Here is that case Steffen was referring to:

STEMI Seen Best in PVC, Diagnosed by Medic, Ignored by Physician

My Comment by KEN GRAUER, MD (10/8/2018):
Our thanks to Dr. Steffen Grautoff for submitting this case that highlights a PEARL for facilitating recognition of acute STEMI by the morphology of PVCs! His case provides a perfect example of how sometimes acute coronary occlusion may only be recognized by PVC morphology!

Figure-1: Compressed version of the ECG in this case (See text).

For clarity — I’ve labeled the compressed 12-lead tracing of this 50-ish year old man with new chest pain (Figure-1).
  • The rhythm is ventricular bigeminy. As per Dr. Smith — assessment of the normal (sinus-conducted) beats on this tracing is not definitive for acute OMI (Occlusion-related Myocardial Infarction). There is slight ST elevation in leads V1 and V2; suggestion of a hyperacute T wave in lead V4 (and possibly V3); and subtle reciprocal change in the inferior leads — but not enough to confirm the diagnosis.
  • As was astutely picked up by Dr. Grautoff — there is enough ECG evidence to confirm acute OMI based on PVC morphology!
  • The most remarkable abnormality in PVC morphology is seen in lead V2. To clarify the points emphasized by Dr. Smith above — I’ve drawn a vertical RED line parallel to solid grid lines that indicates the end of the QRS complex of the PVC in leads V1 and V2. The dotted RED lines follow this demarcation point downward, so as to clarify the end of the QRS complex for the PVC in leads V3-thru-V6, as well indicating the end of the QRS complex for the PVC in the limb leads. The short horizontal YELLOW lines indicate the ST segment baseline.
  • There is no ST segment elevation for the PVC in lead V1 — which is what one normally expects in PVCs when there is no ongoing OMI. However, it should be obvious that the PVCs in leads V2 and V3 manifest significant J-point elevation that just-shouldn’t-be-there. In addition, there is terminal T wave inversion for the PVC in lead V2 (RED arrow). If one steps back a little bit from this ECG to study the appearance of the ST-T wave for the PVC in lead V2 — Doesn’t this look like the ST-T wave appearance of an acute STEMI? (Look within the BLUE rectangle).
  • ST-T wave morphology for PVCs in many other leads manifest exaggerated T wave amplitude — which in the context of the diagnostic PVC morphology changes in leads V2 and V3 is consistent with hyperacute T waves in these PVCs. And, in the context of clear abnormal J-point ST elevation for the PVCs in leads V2 and V3 — the dotted RED lines in leads V3-thru-V6 suggest there is also abnormal ST elevation for the PVCs in these leads. The overall picture strongly suggests acute LAD occlusion!

BOTTOM LINE: The great majority of acute OMI tracings identified by ECG will be diagnosed on the basis of ST-T wave morphology changes in sinus-conducted beats. But over the last decade-plus, since I started paying attention to ST-T wave morphologic changes in ventricular beats — I have seen a surprising number of cases in which acute OMI was evident from morphologic change in the PVCs. And on occasion (as is the case here) — acute OMI may only be evident from assessment of ST-T wave morphology of PVCs.
  • PEARL: If you can identify one or two leads in which there is NO doubt that ST-T wave morphology of the PVCs is abnormal (as is the case here in leads V2 and V3) — it then becomes much easier to appreciate abnormal ST-T wave morphology for PVCs in other leads.


  1. Dr.Smith, your posts are so helpful...Please keep doing it.Thanks.
    Raj Patel, M.D.

  2. Thank you again, I prioritise your posts as they are so relevant. A question though - why do you think this happens? It will be easier to remember if I can hook it to a physiological process...

    1. Kylie,
      Just think of it as ST elevation in a situation where there should not be any.
      Steve Smith

  3. nice post dr Smith, i want to ask, if unifocal PVC has slight STE with RBBB pattern but there is no any STE at other leads (i mean normal beats, origin from SA node), could it be only small infarct area from PVC origin?

  4. great case.thank you dr smith
    i would like to share these two ekg's


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