Saturday, May 13, 2023

What is this strange looking ECG in a young woman?

I was reading EKGs on the system and saw this one, with no other information.

What was my interpretation of these apparently abnormal precordial leads?

Smith: Normal variant ST Elevation and T-wave inversion, probably in a young African American male.

The Queen of Heart PM Cardio Bot also states: "Not OMI with High Confidence"

Additionally, as Ken notes below, the limb leads are reversed.

I later went into the chart:

This was recorded in a young African American female with altered mental status (severe agitation) due to an unidentified intoxicant. She rapidly awoke and was discharged home.   Electrolytes were all normal and troponins negative.   

These ECGs are usually seen in young men, so I was surprised.  Then I found that the patient was a trans female and this explained the findings.

One might be concerned about LVH or HOCM, but a bedside echo had been done.  Here is the parasternal short axis:

This confirms that there is no concentric LVH or HOCM.

This is a normal variant ECG.  It is good to know what is and what is not normal.

Read more about ECG findings in African Americans:

Walsh B. Prutkin J. MacFarlane P. Smith SW.  Distinctive ECG Patterns in Healthy Black Adults.  J Electrocardiology 56:15-23; Sept-Oct 2019.


MY Comment, by KEN GRAUER, MD (5/13/2023):


NOTE: While true (as per Dr. Smith) that the chest leads show normal variant ST elevation and T wave inversion — there is LA-RA Lead Reversal in the limb leads!
  • I suspected this because you shouldn't see a predominantly negative P in lead I — and you shouldn't see such a wide and deep Q in lead I — and there is no upright P in lead II. Instead — We see a nice upright P wave in lead III — and, lead aVR shows a positive P and initially positive QRS.

Below — 
Figure-1 shows the effect that LA-RA Reversal has on these limb leads.
  • In Figure-2 — I corrected for LA-RA Reversal — and now the limb leads look as they should look for a young adult!


Figure-1: The effect LA-RA Lead Reversal has on the limb leads.

Figure-2: I've corrected for LA-RA Reversal. The limb leads in 1B now look as they should for a young adult. 

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