This was texted to me by a former resident. An 80-something woman who presented with chest pain and dyspnea.

This was texted to me.  An 80-something woman who presented with chest pain and dyspnea.What do you think?The rhythm appears to be atrial fibrillation.  In any case, it is clearly a supraventricular rhythm.  There is significant ST depression in V2-V4.  Is this posterior OMI?Before jumping to any conclusions about the significance of ST-T abnormalities, you must first be certain that they are not a result of (secondary to) any QRS abnormalities. Do you see any such abnormalities?There is a large R-wave in V1.  Is this RBBB?  No, it is not RBBB.  The QRS is not wide enough, there are no wide S-waves in V5 and V6.Is it perhaps right ventricular hypertrophy (RVH)?  Look for right axis deviation.  Indeed, there is a deep S-wave in lead I: Right axis.This is RVH.  And RVH often has such secondary repolarization abnormalities: STD in V1-V3, usually also with T-wave inversion.See these cases of RVH:  Elderly woman w shortness of breath and an ECG that helps to understand itSo I texted back:" All the ST depression is due to RVH. See the right axis?? And R/S in V1> 1.  (Large R wave in V1) "And he responded:" Ah yeah. That fits. Had big RV on my bedside US. Thanks!! " An old formal echo was found from 6 mo ago: Dilated right ventricle with septal flattening and estimated right ventricular systolic pressure of 70 mmHg (significant pulmonary hypertension). She ruled out for acute MI by troponins.&nbs...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs