Conclusion to 88 year old male CC: Chest pain

This is the conclusion to 88 year old male CC: Chest pain. You may wish to review the previous post for the history and clinical presentation.

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

Now with the computerized interpretation.

This 12-lead ECG shows bifascicular block and is very suspicious for acute STEMI.

The first thing that jumps out at me when I look at this 12-lead ECG is the concordant T-wave in lead V2.

With right bundle branch block (RBBB) the T-wave should be deflected opposite the terminal (last) wave of the QRS complex. Because the QRS complex ends in an R-wave the T-wave should be negative. However, in this case it is positive. This is sometimes referred to as "pseudo-normalization" of the T-wave with RBBB. You will also note that the ST-segment is slightly elevated.

Now let's take a closer look at the high lateral leads I and aVL.

Do not let your eye be fooled! I have noticed that in the setting of RBBB the S-wave is often "lifted" when ST-elevation is present. That can create the illusion that the ST-segment is isoelectric. In this case, if you look carefully you will see that the J-point is clearly elevated.

It's debatable as to whether or not 1 mm of ST-elevation is present in the high lateral leads but some ST-elevation is present. Remember, the conventional criterion of 1 mm of ST-elevation in 2 or more contiguous leads is a gross oversimplification. However, computerized interpretive algorithms obey the rules and this ECG has not triggered the ***ACUTE MI SUSPECTED*** message (yet).

When ST-elevation is present in the high lateral leads (I and aVL) we should inspect the inferior leads (II, III and aVF) for reciprocal changes. The converse is also true.

ST-depression is present in leads II, III and aVF. If you're not sure of the exact location of the J-point in leads II and III you can find the J-point in lead I and draw an imaginary line straight down to help you find your landmarks. This finding is subtle (most obvious in lead aVF) but to me this is the strongest evidence that the concordant T-wave in lead V2 and slight J-point elevation in leads I and aVL are pathological.

It can't be repeated often enough. When looking at any ECG abnormality "consider the company it keeps." We might blow off a single lead showing a concordant T-wave. We might blow off a single lead showing a slight amount of J-point elevation. We might blow off a single lead showing an inverted T-wave or ST-depression, but put them all together and a picture starts to emerge.

In this case the picture that emerges is a high-risk patient who is almost certainly experiencing an acute coronary syndrome! 

Unfortunately, this crew obtained only one 12-lead ECG and did not recognize these abnormalities. One of the best quotes I've heard about serial 12-lead ECGs came from Tim Phalen. He said, "Taking a single 12-lead ECG is like taking a single photograph of Old Faithful. Is it a geyser, or is it a hole in the ground?" 

One imagines that if this ECG were to have been repeated it would have shown changes to suggest the dynamic oxygen supply vs. demand characteristics of ACS.

On the plus side, this ECG was transmitted to the hospital and the ED physician found it to be suspicious. The 12-lead ECG was repeated in the emergency department (we do not have a copy of this ECG) and a "Code STEMI" was called. The patient was taken to the cardiac cath lab. We do not have a copy of the cath report. However, we do know that for some reason the cath was unsuccessful and the patient was sent to the OR for a 3-vessel CABG.

Diagnosis: Acute ST-elevation myocardial infarction


  • Hesham Mady says:

    so it`s 100% acute ant..Myokardial infarction,,,the ECG`s shows extensive involvement of ant wall…….i want to ask,,,old patient+Acute MI+Circulatory instable——-indikation of PCI??I

  • Most certainly it's an indication for PCI! 

  • Ken Grauer says:

    Excellent post TOM – with superbly explained illustrations.  I'd add a few comments: i) I think it helpful to think of the concept, "shape MORE important than amount" when referring to ST-T changes, especially in the inferior leads – where acute MI will often manifest surprisingly subtle amount of ST changes that nevertheless are diagnostic of acute MI; ii) There are Q waves in leads I, aVL and V1 We don't know if these are new or old (since we don't have a prior tracing to compare) – but the width of the Q in aVL is clearly more than seen with "normal septal q waves" – and that initial "r" of the rSR' characteristic of RBBB is missing in V1 – so infarction has taken place – presumably part of the constellation of ST-T wave changes that you are describing; iii) One might think of the ST-T wave in lead III as a virtual "mirror image" of what is seen in lead aVL (not only the J-point depression, but the T in III being mirror image of the subtle but real hyperacute T in aVL); iv) This patient may well need a pacer at 88 with bifascicular block and in addition 1st degree AV block … (again, not knowing which of these are new vs old). THANKS again for presenting this interesting case! – Ken Grauer, MD (

  • Good points, Ken. This patient is certainly at risk of developing sudden 3rd degree AV block (bifascicular block plus 1st degree AV block plus ACS). I had meant to mention the Q-wave in lead aVL. I did consider that lead V1 showed a qR complex but on closer inspection I thought I hallucinated a tiny little nub of an R-wave! But perhaps it's a Q-wave equivalent none-the-less! 

  • Ken Grauer says:

    While not necessarily "trifascicular block" (I was corrected on this by EP folks a while back) – 88yo + Acute MI + RBBB/LAHB + 1st degree AV block with relative bradycardia certainly stacks the cards, and there'd be a low threshold to pace … I also did a "She loves me- She loves me not – She loves me" triple take at V1, before concluding I'd have to assume we are looking at a Q given the overall context (esp. with the changes you note in V2). Again – EXCELLENT case!

  • based on the story in the original post, i must say that was awfully ballsy of the crew to run exactly one 12-lead.

  • Not ballsy. Complacent or lacking in understanding. There was no malice or arrogance behind it.

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