However, this ECG also meets the voltage criteria for LVH.
Could it be a strain pattern (typical secondary repolarization abnormality)?
No.
It's difficult to tell with the wandering baseline throughout this ECG, but if you line up the point at which the PR-segment hits the QRS complex in leads V1, V2, and V3 you can see that each of these leads shows approximately 4 mm of ST-elevation.
You will recall that with a "strain pattern" the degree of ST-elevation is proportional to the depth of the S-wave in the opposite direction! So the lead with the deepest S-wave should have the most significant ST-T wave abnormality in the opposite direction.
It's not easy to tell the exact depth of the S-wave because the complexes are running together, but these measurements are probably fairly close.
There's no way that a typical strain pattern would show the same amount of ST-elevation in one lead with S-waves that are 22.5 mm deep and another with S-waves that are only 6 mm deep.
Here's the most disturbing finding, in my opinion.
There appears to be reciprocal behavior between the inferior leads and the high lateral leads.
So, if this is a STEMI mimic (for example, benign early repolarization superimposed on top of left ventricular hypertrophy) it's a darned good one!
So what should the hospital do when they are in receipt of a patient like this?
I asked Stephen Smith MD from Dr. Smith's ECG Blog and here's what he said.
"If I were the ED physician, I would aggressively treat the blood pressure with NTG (up to 250 mcg/min or even higher) until the BP came way down. I would do a bedside cardiac ultrasound and look for anterior wall motion. If pain did not go away, and echo did not definitely show good wall motion, I would activate the cath lab."
It's always nice to get Dr. Smith's perspective! I've learned a lot from his blog over the past 2 years. If you're not familiar with his website you should take the time to check it out! His case studies are top notch!
