A 60-something with Syncope, LVH, and convex ST Elevation

Note 2 other similar cases at the bottom that come from my book,The ECG in Acute MI.CaseWhile I was busy seeing patients, a resident brought me this ECG of a 60-something with a history of syncope only. There was no chest pain or SOB at the tim of the ECG:Computerized QTc is 464 msA previous ECG from 8 years prior wasnormal.What do you think?There is sinus rhythm at a rate of nearly 100 (nearly tachycardic)There is 2.5 mm STE in lead V1 and 3 mm in lead V2, withconvexity, and 1.5 mm in V3.This meets " STEMI criteria "However, there is very high voltage, with a very deep S-wave in V2 and tall R-wave in V4.This is massive LVH and the ST elevation is not atypical for LVH withsuperimposed stress.The morphology is not right for STEMI.My interpretation:LVH with secondary ST-T abnormalities, exaggerated by stress,not a STEMI.Is there a formula to help with this? Maybe. See discussion at the bottom.I did not have more information at the time. To the ED providers, the patient denied CP, SOB, or drug use.My opinion was that it was not a cath lab case, but I did suggest they do a bedside ultrasound to look for an anterior wall motion abnormality.Absence of chest pain or SOB at the time of the ECG is important; had the patient had active chest pain, I would have recommended at least an emergency formal echo, if not cath lab activation.This is the ED bedside echo, recorded during ST elevation:Parasternal short axis showshuge concentric LVH. The anterior wall is co...
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