ECG Review

A 54-year-old Man 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.


The ECG shown above was obtained from a 54-year-old man with atypical chest pain. Is there cause for concern?


Our systematic interpretation of the above tracing is as follows: The rhythm is sinus bradycardia at a rate just under 50/min. All intervals are normal. The mean QRS axis is +75°. There is no chamber enlargement. With regard to assessment of Q-R-S-T changes, there is a narrow but fairly deep Q wave in lead aVL; and there are tiny septal q waves in leads V5,V6. Transition occurs normally between leads V3 and V4. The most remarkable part of this tracing lies with assessment of ST-T wave changes, which reveals a number of subtle, but potentially important findings. The ST segment in lead aVL is coved and slightly elevated, with associated symmetric T wave inversion in this lead. Although none of the other lateral leads shows similar changes, the findings in lead aVL may nevertheless be real and possibly acute. As the highest (i.e., most remote) of the 5 lateral leads (I, aVL, V4, V5, V6), there are occasions when lead aVL may be the only lead to show signs of acute infarction. Two other findings on this tracing should prompt cause for concern: 1) Subtle, but real ST segment depression in each of the inferior leads (II, III, aVF), which could reflect reciprocal changes; and 2) T wave peaking in the inferior and antero-lateral precordial leads. Assuming that serum potassium is normal, T wave peaking may occasionally reflect ischemia. Two keys to interpretation of this tracing will be clinical correlation and comparison with a prior tracing so as to determine whether any of the above described changes are new.