ECG of the Week - 20th July 2015 - Interpretation

This ECG is from a 50 year old male who presented with 10 hours of chest pain.
Background history of hypertension and smoking.
Check out the comments from our original post here.

Click to enlarge

Rate:

• 90 bpm

Rhythm:

• Sinus Arrhythmia

Axis:

• Normal

Intervals:

• PR - Normal (~200ms)
• QRS - Normal (100ms)
• QT - 400ms (QTc Bazette 380-400 ms)

Segments:

• ST Elevation leads V1 (2mm), V2 (2-2.5mm), aVR (1mm)
• ST Depression II, III, aVF, V5-6

Additional:

• Voltage criteria LVH
• S wave V1 + R wave V5 = 24mm + 14mm = 38mm
• Left Arial Enlargement

Interpretation:

• LVH
• ST changes proportional to S wave voltage
• ST to S wave ratio <25%

What happened ?

In this case the changes due to LVH were thought to represent acute MI and the patient was taken for urgent angio which was essentially normal.

There are a few nice reviews on LVH and ACS look at decision rules to help distinguish LVH from LVH + acute AMI that I'd recommend:

• http://www.ecg-quiz.com/guidelines/stemi-vs-hypertrophy/
• http://doccottlesdesk.blogspot.com.au/2012/07/distinguishing-stemi-from-lvh-on-ecg.html

Also a number of cases from Dr Smith involving LVH:

• http://hqmeded-ecg.blogspot.com.au/2014/01/st-elevation-and-positive-troponin-is.html
• http://hqmeded-ecg.blogspot.com.au/2013/12/hyperacute-t-waves-anterior-stemi-no.html
• http://hqmeded-ecg.blogspot.com.au/2011/01/not-all-cases-with-reciprocal-st.html
• http://hqmeded-ecg.blogspot.com.au/2011/04/cath-lab-activated-what-do-you-think.html

References / Further Reading

Life in the Fast Lane

• LVH 

Textbook

• Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.