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Home > Columnists > Tom Bouthillet
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EMS 12-Lead
by Tom Bouthillet

Early bird gets the worm: Patient follow-up

Find out what the 12-lead ECG uncovered about the patient

By Tom Bouthillet

-->  Haven't read the initial case presentation? Read: Early bird gets the worm

Let's take another look at the 12-lead ECG.

This 12-lead ECG shows benign early repolarization, a common finding in young males.

The classic presentation is upwardly concave ST-elevation, hooked J-points, and tall T-waves, often most noticeable in lead V4.

This is probably because V4 tends to show the tallest R-waves in the precordial leads. If you look at this example, lead V4 has the tallest R-waves, the most significant ST-elevation, and the tallest T-waves.

Here you can see the classic "hooked J-point" in lead V4 (this finding is not always present with benign early repolarization).

What do we mean by "upwardly concave ST-elevation"?

One easy way to remember is that "upwardly concave" ST-elevation looks like a "smiley face."

It's important to note that acute STEMI can also present with upwardly concave ST-elevation, so the mere fact that ST-elevation is upwardly concave does NOT mean you are dealing with a mimic!

Other findings that point away from acute STEMI are the patient's young age, a chief complaint that is not highly suggestive of ACS, an absence of reciprocal changes, a relatively short QTc, and intact R-wave progression in leads V1-V4.

I can also tell you that there were no changes on serially obtained ECGs.

The GE-Marquette 12SL interpretive algorithm often "catches" benign early repolarization but in this case it gave the ***ACUTE MI SUSPECTED*** message.

That's why it's important to interpret the ECG in light of the history and clinical presentation. It also demonstrates why paramedics should over-read the computerized interpretation. It has a high specificity when it gives the ***ACUTE MI SUSPECTED*** message but as we see here it's not 100 percent.

In this case the patient was transported to the local non-PCI hospital and was worked up for near-syncope. He ruled out for acute myocardial infarction.

About the author

Tom Bouthillet is a Fire Captain/Paramedic with Hilton Head Island Fire & Rescue, Editor-in-Chief of the, Chief Content Architect of, host of the Code STEMI web series at First Responders Network, a member of the Editoral Advisory Board of EMS World Magazine, and developer of the 12-Lead ECG Challenge smartphone app. He has taught nationally in the Critical Care Transport (CCEMT-P) program out of UMBC and his writings have been referenced in the American Heart Journal, the Journal of the American College of Cardiology: Cardiovascular Interventions and the EP Lab Digest. Contact Tom at
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