LVH and Anterior ST Elevation: is it OMI and would you activate the cath lab?

Written by Jesse McLaren (@ECGCases), with comments by Smith and Grauer A 50 year old presented with chest pain radiating to the shoulder. They had a history of an LAD stent 10 years ago and alcohol use disorder, with repeated visits for chest pain and two code STEMIs two years ago that found no occlusive disease. What do you think? There ’s normal sinus rhythm, normal intervals, normal axis, and normal R wave progression. There’s LVH with repolarization abnormalities, including discordant ST depression and T wave inversion inferolaterally and discordant ST elevation and tall T wave in V2. Are there any primary ischemic changes? How can we identify OMI in the presence of LVH? 1. prior ECGs Below are the first and last ECGs from that the visit resulting in a code STEMI, which found a patent LAD stent but no occlusive disease (as per the discharge summary, further angiogram details not available):This shows the benefits and limitations of prior ECG. On the one hand, we can see prior secondary repolarization abnormalities. But we can also see that they fluctuate over time, and can vary with differences in lead placement. 2. proportionality The secondary ST/T changes from LVH can make it difficult to assess primary ischemic abnormalities, and the STEMI paradigm doesn ’t even try—defining STEMI as ST elevation in the absence of LVH. But the OMI paradigm can draw from the principle of proportionality. As Drs. Aslanger, Meyers and Smit...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs