ECG Review

Atypical Chest Pain and an Abnormal ECG

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.

Figure: 12-lead ECG obtained from a 50-year old African American man with hypertension and chest pain.

Clinical Scenario:

The ECG in the Figure was obtained from a 50-year old African American man with hypertension who was admitted to the hospital because of chest pain. His chest pain was intermittent, and of several weeks duration. It was generally short-lived, and not regularly precipitated by activity. He was a non-smoker, and did not abuse cocaine. Blood pressure was significantly elevated. How would you interpret this patient's ECG? Does it suggest acute infarction?


The ECG in the Figure is clearly abnormal. There is sinus arrhythmia and bradycardia. All intervals are normal. The mean QRS axis is +75°. There is voltage for LVH (left ventricular hypertrophy). The most remarkable finding is deep, symmetric T wave inversion in multiple leads. There is also worrisome ST segment coving and elevation in lead V3, and J point ST segment depression in leads II, V5, and V6. In the right clinical setting (and in the absence of a prior tracing for comparison), one would have to interpret these changes as suggestive of acute evolving myocardial infarction. However, the history in this case is not typical for acute infarction in that chest pain is intermittent in occurrence, of short duration, and recurring over a period of several weeks.

In the absence of a prior ECG for comparison, admission to the hospital to rule out acute myocardial infarction was prudent. Serial troponins were negative, and cardiac catheterization was completely normal. The ECG changes seen here therefore represent LVH and "strain" and/or ischemia in a patient with significant hypertension — but not acute infarction. Perhaps this middle-aged African American man also had a similar underlying repolarization variant, accounting for ST segment coving and elevation in lead V3 ... Deep, symmetric T wave inversion as seen here is a common accompaniment of severe, longstanding hypertension.