EKG of the Week

A 40 y/o male presents coming off an airplane c/o a “funny feeling” in his chest.

What does the EKG show?

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Hyperacute T waves with ST elevations in leads V1, V2, I, aVL with reciprocal depressions in leads II, III, and aVF. The patient’s subsequent EKGs are attached. EKG B shows V-fib. EKG C shows ST elevations in leads V1-V6, I, and aVL with reciprocal depressions in leads II, III, and aVF. This is an extensive anterolateral STEMI.

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The earliest electrocardiographic finding in AMI is the hyperacute T wave, which maintains its vector but becomes tall and peaked within minutes of the interruption of blood flow. It is usually broad based and slightly asymmetrical. The hyperacute T wave progresses to ST segment elevation in classic MI. This hyperacuity may not be appreciated on the initial ECG. The differential diagnosis of the tall T wave includes hyperacute T waves of ischemia, hyperkalemia, benign early repolarization (BER), LVH, LBBB, and pericarditis.

(Kurz, Mattu, Brady. Acute Coronary Syndrome. In Rosen’s Emergency Medicine, 8th ed, p. 1003.)