See many morphologies of non-ischemic ECGs from the same patient

 I was reading ECGs on the system when I saw this one (ECG-1):What do you think?My read was " ST Elevation that is NOT ischemic " .  I suspected this strongly because it just doesn ' t " look right " for a STEMI, in spite of the clear STE in V3 and V4.  This STE appears to be due to LVH, even though the STE in V4 is concordant to the QRS.  There were previous ECGs for comparison, so I looked at them:The patient had presented 4 days earlier with chest pain and had several ECGs recorded:Time zero (ECG-2):Scary looking STE, but has features of benign STE, especially in V5 and V6: Tall R waves, relatively short QT interval, LVH voltage in V2 and V3, pronounced J-wave in V4 and slurring of the J-point in V5, V6.There were previous ones to compare to at that time:This is from 13 days prior (ECG-3):Different, but it certainly suggests that ECG-2 is not ischemic.This one has more features of standard LVH: high voltage and discordant STE in V2-V4, tall R-waves in V5 and V6.But concordant STE in V5 is not really typical of LVHThis is from 3 years prior (ECG-4):Different, but it certainly suggests that ECG-2 is not ischemicThis one has lots of concordant STE in V4-V6.So serial ECGs were recorded on that presentation 3 days prior:Time 17 min (ECG-5):About the same as time zero (ECG-2)Time 100 min (ECG:-6)Very similar againThere was a bedside echo.  Here is the parasternal short axis:This shows severe concentric LVHNext AM (ECG-7)Very similar againO...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs