Huge Precordial ST Elevation in an ED Patient

This was sent by Twitike Nthakomwa, a medical officer fromMalawi who knows a lot about ECGs.Here is a 50-something patient who presented without symptoms of MI (simply a cough).  Because a murmur was heard, an ECG was recorded.But this patient could easily develop reflux with chest pain, or chest wall pain, or any number of reasons for non-ischemic chest pain, so it is important to know the range of normal in ECGs.Here is the ECG:There is huge ST elevation, about 5 mm in V2 at the J-point (maybe more).There is also a lot of voltage and this may represent LVH or a thin athletic black maleAs you can see, the physician calculated the 3-variable formulaSTE at 60 ms after the J-point in lead V3 is 4 mmQTc is 424 msR-wave amplitude in V4 = 37 mmI estimate the QRS in V2 as 18 mm.3-variable formula value = 17.74 (very low, far less than cutoff of 23.4)4-variable formula = 13.66 (very low, far less than cutoff of 18.2)Thus, this is early repolarization (normal variant ST elevation) and NOT ischemic STESee here for 3- and 4-variable formulas:12 Cases of Use of 3- and 4-variable formulas to differentiate normal STE from subtle LAD occlusionThey did a bedside echo:This does show LVH and also a small amount of mitral regurgitation.The patient underwent a stress test:Notice almost all the ST elevation is resolved.This is a well known phenomenon: the ST elevation of early repolarization often resolves with stress.Other features are highlighted in the papers referenc...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs