Syncope, History of Coronary Disease, and ST Elevation: Should Medics Activate the Cath Lab?

A 60-something male had a syncopal episode.  911 was called.  The patient had no complaint of chest pain or shortness of breath. A prehospital ECG was recorded:Limb leadsPrecordial LeadsThere is ST Elevation in V1-V3, and in aVL, with reciprocal ST depression in II, III, and aVF.There is also some ST depression in V5 and V6, and ST elevation in aVR.What do you think?The medics interpreted the ST elevation, with reciprocal ST depression, as STEMI, and activated the cath lab.Note that you cannot see the entire QRS on the prehospital ECG.  The R-waves in leads II and III are cut off.  The S-waves in V1-V3 are cut off.  There is likely to be very high voltage that is cut off.It is important to remember that not all ST elevation with reciprocal ST depression is a manifestation of STEMI.  LVH, LBBB, and WPW can all have ST Elevation with reciprocal ST depression. Especially LVH.On arrival, I looked at the ECG and immediately knew it was a false positive due to LVH.An ECG was recorded in the ED:This confirms high voltage. QRS is 118 ms.There is no evidence of STEMI.All ST deviation is a result of LVH withsecondary repolarization abnormalitiesThese are secondary to abnormal depolarization due to LVH, with high voltage.These areexpected ST-T abnormalities given the high voltage abnormal QRS.They are not "primary" ST-T abnormalities of ischemia.This ECG has similarities to Left Bundle Branch Block (LBBB), but it is NOT LBBB because the QRS i...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs