Severe LVH and PseudoSTEMI

An elderly male with end stage renal disease had hypotension (50's systolic) and syncope (LOC, and loss of radial pulses) during dialysis. He quickly regained consciousness.  There was no chest pain or SOB.  The patient has an implanted cardioverter defibrillator (ICD) due to previous cardiac arrest; it did not shock. His BP was 106/59 in the ED, with a pulse of 90.

He had a history of out of hospital cardiac arrest due to ventricular fibrillation and also recurrent ventricular fibrillation/polymorphic ventricular tachycardia, for which he received the Implantable defibrillator.

Previous echo had shown severe concentric LVH.

He also had a h/o CAD with PCI to mid LAD 2011.

Here is his ED ECG:
There is sinus rhythm with a wide QRS at 138 ms.  It is very similar to LBBB, but because of Q-waves in aVL, it does not meet formal criteria.  However, it is surely an intraventricular conduction delay, and all of the rules of appropriate discordance apply.   Applying these rules, there is no concordant ST elevation.  There is discordant ST elevation in V1-V3, and this was very concerning to the clinicians.  It is not, however, out of proportion (ST/S ratio not greater than 0.25).  The highest ST/S ratio is no more than 0.12, within normal limits.  There is also high voltage.

Here is the most recent ECG from 6 months prior:
Sinus rhythm. QRS is 107 ms (much shorter).  There is high voltage.   There was much less ST elevation at this time, and the increased ST elevation concerned the clinicians.  But the QRS is now wider too (new conduction delay) and the heart rate is also much slower and both of these can greatly affect the ST elevation.  A faster heart rate generally exaggerates ST elevation in LVH, LBBB, and paced rhythm.  Finally, the T-wave inversion in V4-V6 is deeper than typical for LVH.  There is a very long QT.

Anterior STEMI is very unlikely here, even though the patient has a history of LAD CAD:

1) there is no chest pain or SOB
2) there is history of severe concentric LVH
3) there is appropriate and proportional discordance
4) the increase in ST elevation compared to the previous ECG can be explained by heart rate.

Nevertheless, there was still concern for anterior STEMI, so a bedside echo was appropriately done:

Here is the parasternal long axis:

This shows severe LV hypertrophy and good wall motion

A short axis echo was done:

This shows severe concentric hypertrophy and no wall motion abnormality.

This allayed fear of possible STEMI and a formal echo was done which also showed no wall motion abnormality.  It confirmed severe concentric hypertrophy with a diastolic septum measurement of 1.76 cm (normal up to 11 mm)

The first troponin returned at 0.50 ng/mL (normal, less than 0.030).  This patient frequently has troponins in the 0.12 - 0.16  range.

This ECG was recorded 8 hours later.
ST elevation persists, now with more upright T-waves

The next troponin was 0.41 ng/mL.

The syncope and hypotension was thought to be due to volume depletion from over-dialysis.  The patient did well.

Learning Point

1. Severe concentric hypertrophy can result in many ECG abnormalities that mimic STEMI and NonSTEMI.
2. LVH may evolve into conduction delay (IVCD).  The rule of appropriate discordance may come into play in IVCD and also in LVH.
3. Heart rate can affect ST segments, particularly in LVH, LBBB, and paced rhythm
4. Bedside echo can help in differentiating ischemic ST elevation from STE secondary to LVH or other etiologies.

I am Dr. Ben Smith, Director of Emergency Ultrasound at University of Tennessee, Chattanooga: How I Work Smarter

How I Work Smarter Logo If anyone in this series deserves the title of true “life hacker”, it’s Dr. Ben Smith (@UltrasoundJelly). A nuclear engineer turned emergency physician, you’ll see it is apparent he takes an engineer’s approach to productivity. In the clinical/education world, he is the Director of Emergency Ultrasound and the Associate Residency Director at University of Tennessee, Chattanooga. He’s a contributing member of FOAM via several websites, including and Although we may not all have the braun the manage our own server infrastructure to host FOAM sites (which Dr. Smith does), he breaks down some simple tips you can use to automate your life and get started on the path to life hacking.


  • Name: Ben C. Smith, MD, FACEPBen Smith Pic Square
  • Location: University of Tennessee, Chattanooga
  • Current job: Director of Emergency Ultrasound, Associate Residency Director
  • One word that best describes how you work: Efficiently-thorough
  • Current mobile device: Samsung Galaxy S4
  • Current computer: 13” Macbook Air i7, the perfect size/weight/battery life. Only thing it lacks is major computing power, if I need that I remote access my desktop or server.

Disclosure: I mention specific services and products here, but I receive no endorsements or remuneration from these vendors.

What’s your office workspace setup like?

Ben Smith Office

i7 Hackintosh Mac Pro

  • 27” Dell Ultrasharp IPS Monitor
    • I’m a big fan of one large, high pixel density monitor for lots of screen real estate.
  • 256 GB SSD for OS X Yosemite and currently active files, 3TB HDD for storage
  • Audio-Technica 2020 microphone: Ditch the tinny laptop mic to sound professional.
  • Novation Nocturn Desktop Controller
  • Keynote/Prezi
  • Photoshop / Lightroom
    • Master Photoshop to produce quality original #FOAMed content.
  • Google Everything / Hangouts
  • if I need to quickly trend some data or generate a graph.
  • Remote access via Screen Sharing

Ben Smith Desk

Ben Smith ServerDell PowerEdge Server

  • Dual hard drives in a RAID 1 array for data security
  • Ubuntu Server Linux / Apache / MySQL / PHP
  • Hosts 4 WordPress websites
  • Backup databases and WP folders on and off site daily (Crashplan)
  • Static content on the zippy Amazon Cloudfront content delivery network (CDN) so my sites are fast anywhere in the world
  • Remote Access via SSH
  • 1 Gb/s fiber optic internet connection, hosted from my office. I am the network admin, server maintainer, and webmaster for the sites above. This saves money.

What’s your best time-saving tip in the office or home?

What’s your best time-saving tip regarding email management?

  • Reply to all important emails within 24 hours.
  • Liberal use of “unsubscribe” links at the bottom of spam.
  • For spam that doesn’t include an unsubscribe link, create a filter to delete or move them to spam folder.
  • Keep a second email address active that you can use to register for various second-third tier online services. I have this email forwarded to my main account and automatically filtered into a separate folder for infrequent viewing.

What’s your best time-saving tip in the ED?

  • Utilize bedside ultrasound early to narrow your differential diagnosis and direct appropriate stabilizing interventions in critical patients.
  • Try to never be the personal cause of ED bottleneck, keep the rack empty, and put the orders in early.
  • When the ED gets really busy, I’m a big fan of thin slicing some orders quickly, then going back later to get a more thorough history once I’m no longer the bottleneck.

ED charting: Macros or no macros?

  • Yes, I do cautiously use macros. The time saved on repetitive documentation outweighs the risk. Main risk is over-documenting, just be certain you know your macros like the back of your hand. For instance, I know my normal physical exam – and I am sure to cover each of these bullet points at the bedside before I click the macro.

What’s the best advice you’ve ever received about work, life, or being efficient?

Is there anything else you’d like to add that might be interesting to readers?

  • As our jobs and lives become more and more intertwined with technology, the benefit to being able to code is skyrocketing. Every professional should learn to code: start small and focus on one programming language early on. Coding concepts and basic constructs cross languages; it is only the syntax that changes.
  • To become productive, simplify. People are always surprised to find out I don’t have the newest laptop or phone. Don’t buy new tech just because it’s new. Ask yourself if you will really use your new gadget before diving in to a purchase. How you use your device is more important than what device you use.
  • I love OS X, it is far more stable than its Windows counterpart. One of my favorite things about OS X is simplified automation using command line bash scripts or, for the more GUI inclined, Applescript.
  • Using keyboard shortcuts helps me streamline my computer work, as they are always faster than mouse clicks (that’s why my favorite text editor is the command line only vi). Here are a few OS X shortcuts I use most frequently:
    • Command-C to copy, Command-V to paste
    • Command-Option-V to paste plain text into gmail (sans formatting)
    • Command-Shift-4 to select an area to save as a screenshot to your desktop
    • Command-Q to close an application
    • Option-control click on a misbehaving program in the Dock and select Force Quit to shut it down (will not save the file you’re working on)
    • Command-Spacebar to open up Spotlight to find a file quickly, Control-Command-Spacebar to do the same search using the Finder
    • Command-Z to undo… just about anything you just did. The most common time I use this one is when I mistype something or accidentally delete a paragraph or two. Want to re-do what you un-did (run-do anyone?): Command-Y.
    • Command-S to save your work. I am personally neurotic about this one, I hit it about once a minute when working on an important file.
  • Do you have a media file embedded in a Keynote or Powerpoint presentation that you’d like to use elsewhere, and you can’t remember where you stashed the original file? First, start by making a copy of your presentation. Then just change the copy’s extension to “.zip” and extract the folder. You’ll find all your files within. This works on modern versions of these applications on OS X and Windows alike.
  • I often find myself needing to do a quick screen recording to demonstrate something or record a lecture, podcast. While there are many paid options, I prefer to use the free one built into Quicktime.
  • I frequently find myself needing to fill-in and sign PDF forms emailed to me (hospital credentialing, anyone?). Instead of downloading the PDF, printing it, filling it out, scanning or faxing it… enter OS X Preview. Just open the file in Preview, then go to the Tools>Annotate>Text Menu to add text to a file. Tools>Annotate>Signature to sign your PDF. When done, hit Command-S to Save, then always “Print to PDF” to save the combined file. Email it back to the sender. You just saved some trees and obviated the need for fax machines.
  • Here are the blogs I read every day
    • Lifehacker – great tips from how to become a successful professional to the best way to cook bacon
    • Gizmodo – science, gadgets. What is more interesting?
    • PetaPixel – must read for fellow photogs

Who would you love for us to track down to answer these same questions?

  1. Mel Herbert (@MelHerbert)
  2. Mike Cadogan (@sandnsurf)
  3. Scott Wieters (@jscottwieters)

Author information

Benjamin Azan, MD

Benjamin Azan, MD

Emergency Medicine Resident

Icahn School of Medicine at Mount Sinai

Founder/Editor of

The post I am Dr. Ben Smith, Director of Emergency Ultrasound at University of Tennessee, Chattanooga: How I Work Smarter appeared first on ALiEM.

ECG of the Week – 27th April 2015 – Interpretation

Some old ECG's from my collection for this week. These ECG's are from an 80 yr old female who presented with pre-syncope. The three ECG's were performed over the course of an hour. Check out the comments on our original post here.

Click to enlarge 
  • 54 bpm
  • Irregular
  • No clear P waves
  • Single ventricular ectopic seen in leads V1-3
  • Normal
  • QRS - Prolonged (120ms)

  • ST Elevation lead aVR, V1-2
  • ST Depression leads I, II, V4-6


  • T wave inversion leads I, aVL
  • LBBB like Morphology
    • QRS >120ms, Deep S wave leads V1-2, Broad R wave in lead I

Click to enlarge
  • 48 bpm
  • Irregular
  • No clear P waves
  • Single ventricular ectopic now seen in leads V4-6
Axis & Intervals

  • Unchanged

  • ST Elevation lead aVR, V1-2
  • ST Depression leads I, II
    • Unable to comment on native activity in leads V4-6 due to only partial complex included


  • Possible U wave in leads V2-3
  • T wave inversion leads I, aVL
  • LBBB like Morphology
    • QRS >120ms, Deep S wave leads V1-2, Broad R wave in lead I

Click to enlarge
  • 78 bpm
  • Irregular
  • No clear P waves
Axis & Intervals

  • Unchanged


  • ST Elevation lead aVR, V1-3
  • ST Depression leads I, II, aVL, V4-6


  • Possible U wave in leads V2-3
  • T wave inversion leads I, aVL
  • LBBB like Morphology
    • QRS >120ms, Deep S wave leads V1-2, Broad R wave in lead I
Key Features
  • Variable rate AF
    • From bradycardia to rate controlled
  • Dynamic ST segment changes comparing ECG 3 with the others ST segment changes appear more pronounced

I don't have any further information on this case but there are a broad general list of differentials for these ECG features including:
  • Ischaemia
  • Sinus Node Dysfunction
  • Electrolyte abn
  • Drug effect especially digoxin
  • Drug toxicity including digoxin, CCB, beta-blocker
  • Endocrine – hypothyroid
  • Environmental - hypothermia
References / Further Reading

Life in the Fast Lane

  • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.

ECG of the Week – 4th May 2015

This week's ECG is from a 70 yr old male who presented following an episode of syncope.
Nil significant medical history or medications. He complained of light-headiness at the time of clinical review. BP, Sats, RR, temp and BSL were all within normal limits.

Click to enlarge 

Things to think about

  • What are the key features on the ECG ?
  • How would you manage this patient ?
  • What specific ECG phenomenon can be seen on this ECG ?