A 40-something male with epigastric pain

A 40-something male presented with epigastric pain.

An ECG was recorded immediately (time zero):

This was texted to me asking for my opinion.
What do you think?

My answer: Normal variant




He had serial ECGs:

This was recorded at t = 40 minutes:

Subsequently, the patient was diagnosed with cholecystitis.

This was recorded at t = 110 minutes

Notice there is some change from ECG to ECG, but this is not uncommon in these normal variants.

That you cannot entirely rely on the temporal stability of the ECG to diagnose normal variants is, to use a favorite phrase, "Sad!".

All serial troponins were below the level of detection.

Learning points

How does one recognize one such ECG as ischemic and one as normal variant?  Why are these not Wellens' waves?

All I can say is that you need to read many many ECGs and get experience and follow up on the outcomes of your interpretations!  There are many cases on this blog that can help you to recognize the difference.

ECGs are like faces: you can easily tell different person's faces from one another, even though they mostly have the same features: 2 eyes with eyebrows, a nose, cheeks, mouth and lips, etc.  How do you describe the difference?  And yet you know it because of your experience with seeing tens of thousands (or more!) of faces over a lifetime.

Unfortunately, doctors who spend a lifetime learning to recognize such patterns eventually retire or die, and all that knowledge is lost.

We are working to produce a Deep Neural Network ECG algorithm that will learn forever.  It is sad for experts that such a network may one day replace human expertise, but very good for patients.

Here are other examples of normal variants with T-wave inversion that look scary:

Persistent Juvenile T-wave Pattern

8 year-old with report of "syncope and an abnormal ECG"

Right Precordial T-wave Inversion

Here are cases of normal variant ST elevation that looks scary:

High ST Elevation in a Patient with Acute Chest Pain

A 50-something year old with typical chest pain

Several Cases of ST Elevation from Early Repolarization

Middle Aged Male with Burning Chest Pain -- Assess the Entire Clinical Scenario

A middle-aged male presented with “burning” mid chest pain, with radiation to bilateral shoulders (pain radiating to both shoulder is very specific for ischemia).  It started about 5 hours prior to arrival.  He obtained little relief from nitro x 3 by EMS.  There was a history of previous MI, with a stent in the 1st Obtuse Marginal.  He had taken his Plavix for 6 months, then discontinued and also stopped taking his antihypertensives and statin.  He continued to smoke about 1.5 pks per day.

Here is his ECG:

Junctional Bradycardia (this is sinus arrest with junctional escape, and is highly suggestive of ischemia).
  There is a pathologic Q-wave in lead III (old? new?).  
There is slight ST depression in leads I, II, and V3-V6 (fairly specific for ischemia). 
Down-Up T-wave in aVL: very specific for ischemia! 
There are slightly hyperacute T-waves in inferior leads (probable ischemia). 

These are subtle findings.  No single finding is diagnostic of ischemia but he has a very specific combination of factors:

1. typical pain
2. h/o coronary disease
3. pain radiating to both shoulders
4. junctional bradycardia
5. Q-waves
6. ST depression
7. Down-Up T-wave in aVL
7. Possible hyperacute T-waves 

All of these together, but none of them by themselves, diagnose acute MI.

One of my former residents diagnosed this as inferior MI and activated the cath lab.  I love it when my residents become better than I at reading ECGs!

There was a 100% acute occlusion of the RCA, with ischemia of the SA node causing sinus arrest.

Lesson:

1. When highly suggestive ECG signs of ischemia combine with a high pretest probability and refractory ischemic pain, activate the cath lab even if the ECG does not meet STEMI criteria.