ECG Review

A Patient with Chest Pain

By Ken Grauer, MD, Professor, Department of Community Health and Family Medicine, University of Florida. Dr. Grauer is the sole proprietor of KG-EKG Press, and publisher of an ECG pocket brain book.

Clinical Scenario

The ECG shown above was obtained from a patient who was seen in the office with atypical chest pain. Is there cause for concern?


The rhythm is sinus at a rate of about 60/min. The axis and all intervals are normal. There is no chamber enlargement. The principal findings of concern are the subtle but definitely present ST-segment depression in each of the inferior leads that occurs in association with equally subtle but nevertheless present ST-segment elevation in lead aVL. There is non-specific ST-segment flattening in several other leads. This tracing provides an excellent example of how shape more than amount is often the key for assessing the significance of ST-T wave changes. While the amount of ST-segment deviation is minimal in this tracing—the pattern of changes seen here in a patient having chest pain could reflect acute evolving infarction (or perhaps a later phase in a patient who recently infarcted). Clinical correlation and comparison with prior tracings would be invaluable for clarifying the situation. A final point is the fact that the remote high lateral lead aVL can at times be the only lead showing ST-segment elevation with acute infarction.