A female in her 60s who was lucky to get expert ECG interpretation

Submitted and written by Alex Bracey, with edits by Pendell Meyers and Steve Smith:I was walking through the critical care section of the ED when I overheard a discussion about the following ECG. I had no history on the case and no prior ECG for comparison.What do you think?Here are inferior leads, and aVL, magnified:A closer inspection of the inferior leads and aVLSinus bradycardia. The T-wave in lead III is slightly tall and broad (increased area under the curve) compared to its QRS complex. In isolation, this probably could not be called a hyperacute T-wave, but you may suspect it.  There is T-wave inversion (TWI) in aVL.  T-wave inversion in aVL: when is it abnormal?There is no LVH or LBBB on which to blame the TWI (i.e., the QRS is normal). While T-wave inversion in aVL may be normal in the presence of a normal QRS, this is only true when the T-QRS angle is small. That is to say, when the T-axis and QRS axis are similar. In other words, if the QRS is negative, the T-wave may be negative. However, here QRS axis is about 25 degrees and the T-axis is about 85 degrees. Thus the T-QRS angle is 25 - 85 = (-60) degrees, which is abnormal. Any absolote value greater than 45 degrees is suspicious for T-wave inversion(however, this is very complex; see table posted at the bottom of this post.)Now that we know the T-wave inversion in lead aVL following a normal QRS complex is abnormal, it helps to confirm that the T-wave in lead III is indeed hyperacute. Th...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs