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Guess What the Cath Shows?
|Figure. 12-lead ECG obtained from a 33-year old man with atypical chest pain.|
By Ken Grauer, MD, Professor, Department of Community Health and Family Medicine, University of Florida. Dr. Grauer is the sole proprietor of KG-EKG Press, and publisher of an ECG pocket brain book. Dr. Grauer reports no financial relationship to this field of study.
Clinical Scenario: The ECG in the Figure was obtained from a 33-year old man who was admitted to the hospital with atypical chest pain because of this tracing. Guess what troponins and his cardiac catheterization report showed?
Interpretation/Answer: The rhythm is sinus bradycardia at 55/minute. All intervals are normal. The mean QRS axis is +75°. Voltage is probably normal given the patient's young age. The most remarkable part of the tracing is the ST-T wave morphology in the anterior precordial leads. Although the appearance of the ST-T wave in lead V1 is not by itself abnormal, it occurs here in the context of coved ST segment elevation and T wave inversion in lead V2. The abnormality continues in lead V3. Admittedly, the ST segment is not significantly elevated in lead V3, however it remains coved with accompanying T wave inversion. ST segment coving resolves between leads V4 to V5.
This is an obviously abnormal ECG. If the clinical setting was the occurrence of this tracing in an older patient with risk factors and the sudden onset of crushing chest pain, one would strongly suspect acute evolving myocardial infarction. However, the patient in this case was relatively young with no history of cocaine abuse, and his chest pain was atypical. In the absence of a prior ECG for comparison, the prudent course of action was still to admit the patient to the hospital to rule out acute infarction. Serum troponins were all normal. Cardiac catheterization showed completely clean coronary arteries with normal ventricular function.
There are a number of normal variant repolarization patterns that are commonly seen in otherwise healthy individuals. Although most often seen in athletic, young adult African American males, similar ECG patterns may also be seen in sedentary, older, Caucasian men or women. Because the normal variant repolarization pattern in this case manifests ST segment coving with elevation and T wave inversion, it would be easy in a patient with chest pain to mistake this tracing for acute evolving infarction. This healthy 33-year-old man was given a miniaturized wallet copy of his ECG, and told to show it if ever he again presented to an ED with chest pain.