This is the ECG of a 45 year old man with H/O hypertension and chest pain .The general practitioner who first saw him alerted this patient about a possible heart attack asked to meet a cardiologist immediately. The cardiologist who saw this ECG tended to confirm the diagnosis and advised admission in a coronary care unit .
The patient defied both and somehow landed in my echo lab . Looking at the ECG I also expected it to be a STEMI evolving into a Non Q MI .
I was surprised to find only LVH with absolutely no wall motion defect . There was no evidence of ASH, HOCM or apical cardiomyoapthy as one of my fellows initially suspected . His EF was 70 %. Cardiac enzymes were sent by then. When I spent few minutes with him , listening the history , it was very clear what he had was non cardiac pain . In the anxiety , no one got it right about the character of pain ,which was localised , lasted for few seconds and least suggesed angina.
The moral of the story is listen to the patient however dramatic the ECG may look !
What is special in this ECG ?
It is common for LVH with ST depression to be mistaken for ACS/NSTEMI
Here , there were other observations that added more complexity .
- Presence of ST/T changes in inferior leads(ST elevation in lead 3)
- Bi-phasic T wave in v1 to v3
- ST elevation in precardial leads
In LVH it is usual to note ST depresion , how do you explain ST elevation in LVH ?
ST elevation in LVH may occur in leads v1 to v3 . It is very rare for LVH to inscribe ST elevation in v4 v5 v6 . Why certain leads elevate the ST segment while others depress in LVH is not clear. It may represent incomplete LBBB pattern where the ST segment deviates opposite to the dominant QRS complex. Septal hypertrophy often elevate while free wall hypertrophy depress the ST segment . Since V5,V6 leads are free wall oriented , these leads record classical ST depression .
Importance of Bi-Phasic T waves
Please remember Bi phasic T waves are notorious for it’s unpredictability. An innocuous looking bi-phasic T waves (especially with dynamic behavior ) is a harbinger of proximal LAD or even left main disease.
Finally , what will be ECG changes if a patient with classical LVH who develops a real STEMI ?
- LV strain pattern normalises ?
- Further ST depression occurs ?
- No great changes . ECG Looks near normal ?
Answer : ?