Infarction and LVH
Report:
Sinus rhythm 86/min
Left anterior hemiblock
LAD -40o
LVH with ST/T changes
Poor R wave progression
ST segment depression suggestive of infarction/ischæmia
Comment:
Like the previous case, this one has some ST segment elevation in V1 and aVR (also in lead 3, but this could be ascribed to LVH and the hemiblock alone). In V1 the S wave is large and the ST segment concave: it does not, unlike the previous case, suggest ischaemia or infarction. Nobody would be tempted into considering ST segment elevation infarction here. Other precordial leads, however, have “plane” ST segment depression typical of ischæmia or non-Q infarction. This depression is concordant with S waves, further strengthening its ischæmic mechanism: LVH alone does it only in leads with prominent R waves (like 1 and aVL here).
It so happened that she had a “baseline” ECG taken in the Outparients a few days before (Fig 13a). Pure LVH with ST/T changes, not even a hemiblock.
Anyway, she had a non-Q or, more fashionably, non-STE infarction (on troponin and CPK grounds). She died two days later, on dobutamine infusion. Should more have been done, at her age? Unanswerable question: I do not know all the facts.
Only one ECG feature was in her favour on admission: she did not have T wave inversion as well as ST segment depression in V4-612. Not enough.
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