ECG Identification

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Chief Complaint

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Just wanted some of your input as to what is going on in this ECG. Doing some LP 15 training and this is part of the strip taken from a coworker. I didnt snap a pic of the entire strip because i figured it would be too hard to see any detail in such a small pic. Can provide it if needed though.

Interpretation by the LP 15 is possible anteroseptal infarct. My coworker is a healthy 31 year old male. Is there such a thing as benign ST elevation? Not sure what to make of this.

100MEDIA_IMAG0122.jpg
 
The STE is small enough that it looks inconclusive?
 
None of the J points are elevated to the point if concern.

A good example of why you need to know how to interpret a 12 lead and not just read what's in the strip.
 
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LVH at most...?


Lesson 1: machine interpretation is secondary provider interpretation is primary.

ECG machines are very sensitive and rarely give patients "Normal Sinus without abnormalities" as a diagnosis. I'm 23 years old in great shape and it finds a fake problem with my ECG every time.
 
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Not really clear if those are Q waves -- doesn't look like it. I would also check lead placement. But that pattern of elevation is classic for BER. Check inferior leads for reciprocal changes, but generally should not be too concerning.
 
Chief Complaint said:
Just wanted some of your input as to what is going on in this ECG. Doing some LP 15 training and this is part of the strip taken from a coworker. I didnt snap a pic of the entire strip because i figured it would be too hard to see any detail in such a small pic. Can provide it if needed though.

Interpretation by the LP 15 is possible anteroseptal infarct. My coworker is a healthy 31 year old male. Is there such a thing as benign ST elevation? Not sure what to make of this.

100MEDIA_IMAG0122.jpg
Click to expand...

Normal QTc and he maintains great R-wave's in V4 and the T-waves are not overly large. I think V1-V3's placement may be suspect (1ICS too high?).

Regardless, even with a chest pain complaint this would be a non-acute ECG.
 
There is a lot of "benign" ST elevation out there. Early repolarization, as Brandon noted, is very common in young males. The "slurred" J-points in V4, V5 suggest this.

But by my eye, and the computerized J-point calculations, the elevations are most pronounced in V2 & V3, where the complexes don't look like BER.

Although it's not quite as "benign," ventricular hypertrophy is a very common STEMI mimic. The ECG pattern suggests this, and also meets voltage criteria for LVH.

This would be unlikely, of course, in a truly healthy (no HTN) 31 y.o.
 
Great responses, much appreciated.

I dont know much about STEMI mimics so this info is quite valuable to me. So if ST elevation doesnt reach 1mm its of no concern (in a healthy patient)? What about a patient who is symptomatic?
 
Chief Complaint said:
Great responses, much appreciated.

I dont know much about STEMI mimics so this info is quite valuable to me. So if ST elevation doesnt reach 1mm its of no concern (in a healthy patient)? What about a patient who is symptomatic?
Click to expand...

Millimeters aren't a great indicator.

You can have 0.5mm of ST-E in only aVL and 0.5mm ST-D in the inferior leads and have a full blown lateral STEMI.

You can have 6mm of ST-E in V2 and V3 with 50mm deep S-waves and not have a STEMI at all.

In a healthy patient you can see some J-point elevation with early repolarization, which doesn't look the same as the elevation in a STEMI. The concavity is usually different and the anatomical distribution is different (or in the case of STEMI, rarely global).
 
This is a bit of a large topic to get into ad hoc. I'd link external resources but apparently the moderators frown on that. At least three different non-ACS causes of ST elevation have been mentioned or alluded to already: BER, LVH, and LVA. (Also possibly electrode misplacement.) Fairly minor elevation is often a feature of these mimics, but there's a lot more to differentiating this stuff.

Of course, the old "treat the patient" approach is obviously relevant too (or for the Bayesians, pre-test versus post-test probability).
 
True dat.

For a discussion of a few ways of being fooled by the STEMI-imposters, you might want to check out a review at An Alternative Method of ECG Interpretation.

After that, you have to hit the examples at EMS 12-lead and Dr. Smith's ECG Blog - plenty of great examples and discussions at those two websites!

Added: Ah, do they they take a dim view of such links? Those last two blogs are solely educational & non-profit, so I hope that's okay.
 
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FYI, we don't allow self-promotions, members aren't allowed post links to commercial websites they own or have interest in.

Post to all the online resources you want, we just ask that they're not yours.
 
Okay, well -- here's a video lecture on the subject of "STEMI or the other thing?"

And as Kelly linked, EMS 12 Lead is the seminal source for this kind of thing online.
 
I once had a call at a clinic for a "STEMI". Pt was a young, healthy black male who came in with a headache, so God knows why they did a 12 lead... Anyhow, he had significant ST elevation (>5 mm) in several leads and the staff at the clinic was pitching a fit. They were miffed that I judged it to be an early repolarization abnormality, although I did agree that we ought to bring him in for further evaluation, although I withheld the typical ACS treatment. An interesting learning moment.
 
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