Unusual ST Elevation in V1 and V2, and LVH, in a Patient with Chest Pain

p.p1 {margin: 0.0px 0.0px 0.0px 0.0px; font: 11.0px Helvetica; background-color: #fefefe}This ECG was texted to me:Computerized QRS is 114 msWhat do you think?There is an rSR ' in V1 and a qR in V2, suggesting incomplete RBBB. There is some concordant ST elevation (concordant to the R ' -wave) in both those leads and T-wave inversion in V5 and V6. But V3 is normal without any evidence of STEMI, and with a low voltage T-wave.  And there is very large voltage in aVL that is diagnostic of LVH. LVH can produce a wide variety of pseudoSTEMI patterns.Here was my response: p.p1 {margin: 0.0px 0.0px 0.0px 0.0px; font: 12.0px Helvetica}" Not a STEMI.  Unusual but does not look right for ischemia. If you suspect MI, get an echo.  I ’ll bet the anterior wall is fine. "He did suspect MI. Here was the history: A middle-aged male with a family history of MI, history of hypertension, and who is a smoker, complained of substernal tightness that started several hours prior ( " after eating pizza " ). He was nauseated but there was no diaphoresis or radiation of the chest discomfort.Not a STEMI. Unusual but does not look right for ischemia. If you suspect MI, get an echo. I ’ll bet the anterior wall is fine.There was an ECG from 3 months ago available for comparison:Very differentQRS is 107 ms.So the incomplete RBBB is new.There was LVH by voltageBaseline ST elevation is even greater, due to LVHHere are the ED cardi...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs