Early bird gets the worm: Patient follow-up
Find out what the 12-lead ECG uncovered about the patient
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.
Recommended Tom Bouthillet
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