A 53 year old male presents to ED complaining of chest pain. Below is his ECG:

Describe and Interpret the ECG

Answer

Rate: 72 beats per minute

Rhythm: Normal Sinus Rhythm

Axis: Normal Axis

Intervals

PR: 160ms

QRS: 100ms

QTc: 482ms

Additional:

• Voltage criteria for LVH: SV1 + R V6 >35mm, aVL > 11mm, R I + S III>25mm
• giant inverted Twaves in inferolateral leads with some ST depression

Differential diagnosis for this ECG in the context of chest pain would be ACS, however this patient has voltage criteria for LVH. The non voltage criteria for LVH with hypertrophic cardiomyopathy are usually smaller inverted T waves that are asymmetrical. With Apical Hypertrophic Cardiomyopathy however, there is giant Twave inversion as seen on this ECG. Apical Hypertrophic Cardiomyopathy is also referred to as Yamaguchi Syndrome and is seen mainly in people of Japanese decent.

In the correct clinical context these giant inverted T waves and prolonged QT can be associated with raised intracranial pressure from a cranial bleed.

This patient went on to have a normal angiogram, but had an echo that showed Apical Cardiomyopathy.

Thank you Dr Shenoy for the ECG