LVH with expected repolarization abnormalities, or acute OMI?

A patient with DM presented with acute chest pain.Here was his ED ECG:There isLVH in limb leads, with a 17 mm R-wave in aVL, and deep S-wave in inferior leads.With this much voltage, one expects some repolarization abnormalities.Indeed, there is a bit of ST depression in aVL (discordant to the tall R-wave) that does not appear to be out of proportion.There is inferior ST Elevation, but the S-waves are also of high voltage.Is this an inferior STEMI?  Or is the LVH with expected repolarization abnormalities? There is also some ST depression in V2.  Possible posterior involvement?CommentTo me, the inferior ST Elevation is out of proportion to the S-wave.  This is however a subjective opinion, as I do not have any data-based rule.  If you measure it, the STE is 2.5-3.0 mm at the J-point, relative to the PQ junction.  With an S-wave amplitude of 17 mm, this is a ratio of 14.6 - 17.6 %.  Without any formal research data to support my opinion, I have advocated that, in LVH, a ratio greater than 15% is abnormal and highly suspicious for STEMI.  (The article by Armstrong  that advocates 25% in V1-V3 for anterior MI is severely flawed and should not be used -- see my comments at the bottom of the page and the associated post).Here is a great example of limb lead LVH with inferior PseudoSTEMI. (Thanks to Life in the Fast Lane for this one).Notice the high voltage.  Notice that there is STE in III with reciprocal STD in aVLThe r...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs

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