A man in his 50s with abdominal pain and a computer read of ***Acute MI ***

 Submitted by Dr. Arjun J V, Written by Pendell MeyersA man in his 50s with history of diabetes presented with acute onset abdominal pain and nausea.Here is his ECG at triage:What do you think?Sinus bradycardia. The QRS is narrow but very abnormal with significant LVH. There are widespread, dramatic, and discordant ST and T wave deviations which are due to the LVH. Look at leads III and aVF here for a particularly important lesson for your eyes. In these leads, the QRS does not actually have radically large QRS voltage, but yet there is substantial (easily meeting STEMI criteria) ST elevation which is due to LVH strain pattern and somewhat reciprocal to the large STD in the high lateral leads which has the perfect morphology for LVH strain pattern in I and aVL. This is an example of how sometimes a widespread repolarization abnormality may seem relatively more disproportionate in a few leads when the QRS is slightly smaller for whatever reason. I find that this is usually very important for precordial transition lead, in which the QRS may be " pulled " in both directions, sometimes making the ST segment and T wave seem concerning for that lead. One clue to recognizing that such STE that is out of proportion to the QRS is the presence of a " saddleback " .  See in lead III how the R-wave and T-wave form a saddle.  This is especially true when you have a saddleback in lead V2; ST Elevation with saddleback in V2 is very rarely due to OMI.In the context o...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs