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Male in his 40's with chest pressure: what is the diagnosis

Posted Sep 04 2012 2:57pm
This 40-some year old patient complained of chest pressure and had this ECG recorded
See comments and diagnosis below

The providers were a bit worried about this ST elevation and I was in the department, so they showed it to me: my answer took 2 seconds and was unequivocal: LVH and early repolarization, no STEMI.

How did I know this?  Primarily because
If inferior MI, there would be significant ST depression in aVL.
If anterior MI, there would not be such high voltage, especially in lead V4.

Though the early repol/anterior STEMI formula may give false positives in LVH (I'm actually not sure of this), the value obtained after plugging in STE60V3 = 5 mm, QTc = 400 ms, and R wave V4 = 33 mm = 18.2 (far less than 23.4, strongly arguing against anterior STEMI).  I did not use the formula, but one could do so and be reassured.

My colleagues appropriately did a bedside ultrasound and found completely normal function.  They did admit him for "rule out" and all troponins were negative.

Diagnosis: Anterior and "inferior" ST elevation due to LVH and early repolarization
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