ECG Identification

[Chief Complaint]

Just wanted some of your input as to what is going on in this ECG. Doing some LP 15 training and this is part of the strip taken from a coworker. I didnt snap a pic of the entire strip because i figured it would be too hard to see any detail in such a small pic. Can provide it if needed though.

Interpretation by the LP 15 is possible anteroseptal infarct. My coworker is a healthy 31 year old male. Is there such a thing as benign ST elevation? Not sure what to make of this.

 

[Summit]

The STE is small enough that it looks inconclusive?

 

[usalsfyre]

None of the J points are elevated to the point if concern.

A good example of why you need to know how to interpret a 12 lead and not just read what's in the strip.

 

[NYMedic828]

LVH at most...?


Lesson 1: machine interpretation is secondary provider interpretation is primary.

ECG machines are very sensitive and rarely give patients "Normal Sinus without abnormalities" as a diagnosis. I'm 23 years old in great shape and it finds a fake problem with my ECG every time.

 

[Brandon O]

Not really clear if those are Q waves -- doesn't look like it. I would also check lead placement. But that pattern of elevation is classic for BER. Check inferior leads for reciprocal changes, but generally should not be too concerning.

 

[Chief Complaint]

Thanks for the input!

 

[Christopher]

Just wanted some of your input as to what is going on in this ECG. Doing some LP 15 training and this is part of the strip taken from a coworker. I didnt snap a pic of the entire strip because i figured it would be too hard to see any detail in such a small pic. Can provide it if needed though.

Interpretation by the LP 15 is possible anteroseptal infarct. My coworker is a healthy 31 year old male. Is there such a thing as benign ST elevation? Not sure what to make of this.

Normal QTc and he maintains great R-wave's in V4 and the T-waves are not overly large. I think V1-V3's placement may be suspect (1ICS too high?).

Regardless, even with a chest pain complaint this would be a non-acute ECG.

 

[KellyBracket]

There is a lot of "benign" ST elevation out there. Early repolarization, as Brandon noted, is very common in young males. The "slurred" J-points in V4, V5 suggest this.

But by my eye, and the computerized J-point calculations, the elevations are most pronounced in V2 & V3, where the complexes don't look like BER.

Although it's not quite as "benign," ventricular hypertrophy is a very common STEMI mimic. The ECG pattern suggests this, and also meets voltage criteria for LVH.

This would be unlikely, of course, in a truly healthy (no HTN) 31 y.o.

 

[Chief Complaint]

Great responses, much appreciated.

I dont know much about STEMI mimics so this info is quite valuable to me. So if ST elevation doesnt reach 1mm its of no concern (in a healthy patient)? What about a patient who is symptomatic?

 

[Christopher]

Great responses, much appreciated.

I dont know much about STEMI mimics so this info is quite valuable to me. So if ST elevation doesnt reach 1mm its of no concern (in a healthy patient)? What about a patient who is symptomatic?

Millimeters aren't a great indicator.

You can have 0.5mm of ST-E in only aVL and 0.5mm ST-D in the inferior leads and have a full blown lateral STEMI.

You can have 6mm of ST-E in V2 and V3 with 50mm deep S-waves and not have a STEMI at all.

In a healthy patient you can see some J-point elevation with early repolarization, which doesn't look the same as the elevation in a STEMI. The concavity is usually different and the anatomical distribution is different (or in the case of STEMI, rarely global).

 

[Brandon O]

This is a bit of a large topic to get into ad hoc. I'd link external resources but apparently the moderators frown on that. At least three different non-ACS causes of ST elevation have been mentioned or alluded to already: BER, LVH, and LVA. (Also possibly electrode misplacement.) Fairly minor elevation is often a feature of these mimics, but there's a lot more to differentiating this stuff.

Of course, the old "treat the patient" approach is obviously relevant too (or for the Bayesians, pre-test versus post-test probability).

 

[KellyBracket]

True dat.

For a discussion of a few ways of being fooled by the STEMI-imposters, you might want to check out a review at An Alternative Method of ECG Interpretation.

After that, you have to hit the examples at EMS 12-lead and Dr. Smith's ECG Blog - plenty of great examples and discussions at those two websites!

Added: Ah, do they they take a dim view of such links? Those last two blogs are solely educational & non-profit, so I hope that's okay.

 

[MMiz]

FYI, we don't allow self-promotions, members aren't allowed post links to commercial websites they own or have interest in.

Post to all the online resources you want, we just ask that they're not yours.

 

[Brandon O]

Okay, well -- here's a video lecture on the subject of "STEMI or the other thing?"

And as Kelly linked, EMS 12 Lead is the seminal source for this kind of thing online.

 

[TheLocalMedic]

I once had a call at a clinic for a "STEMI". Pt was a young, healthy black male who came in with a headache, so God knows why they did a 12 lead... Anyhow, he had significant ST elevation (>5 mm) in several leads and the staff at the clinic was pitching a fit. They were miffed that I judged it to be an early repolarization abnormality, although I did agree that we ought to bring him in for further evaluation, although I withheld the typical ACS treatment. An interesting learning moment.