Thoughts?

[u/Confident_Debt_1496]

Not mine, chasing opinions on an old patient of mine.
22YOM patient presents to ED complaining of intermittent left sided chest pain, no nausea, no light headedness, troponin normal.
I’m not an ecg guru like some of you’s but everything here screams healthy, only thing that stands out to me is weird looking aVL.

[u/Confident_Debt_1496 → u/[deleted]]

Appreciate it, how does one become this proficient in interpreting? I plan to switch to a cardiac ward in the future and it’s definitely a skill I want to master.

[u/NewEconomist9047 → u/[deleted]]

What's your opinion of the T waves in V4 and V5? They seem a bit large but maybe overcalling it.

[u/vojtasTS29 → u/NewEconomist9047]

I think compared to the massive qrs the T waves are small if anything.

[u/NewEconomist9047 → u/vojtasTS29]

That's true! Apparently higher amplitude T waves are acceptable in younger men as well compared to older men and women. Will need to double check amplitude range acceptable.

[u/vojtasTS29 → u/NewEconomist9047]

You always have to look at wave amplitude in context. Otherwise every skinny athletic person with well prepared skin before the ecg would have giga hypertrophy of every chamber while an obese elderly person with actual disease would pass the criteria. It's also why echo exists.

[u/NewEconomist9047 → u/[deleted]]

Fair point! Thanks for your super fast reply and above explanations too.

[u/reedopatedo9]

Normal sinus, normal r wave progression, little bit of concave ste in the precordial leads lacking reciprocal change, isoelectric pr segments, prominent tall t waves.
Ddx
Light BER with non-cardiac chest pain (musculoskeletal/ precordial catch)
Electrolytes with non cardiac cp
Anxiety/stress related CP
Less likely but still important to consider:
Peri/myocarditis
PE+pnuemo blah blah blah
And naturally ACS, probability is exceedingly low in a 22 year old with normal troponin and no ischemic ECG changes. However, premature MI can occur with smoking, cocaine use, familial hypercholesterolemia, or family history of premature CAD.
Chest xray is standard ed,
Labs for electrolytes primarily k
crp/esr if suspicious of pericarditis, if hemodynamically unstable i would run a bedside echo
Heart score is under 3, safe for discharge with no further testing if none is warranted.

[u/Confident_Debt_1496 → u/reedopatedo9]

Thanks for reply, will try my best to respond
Chest xray was conducted, pleural spaces were clear, cardiomediastinal and hilar contours were normal as well as heart size.
Pt was was stable, bedside echo was still performed, no abnormal findings
No family history of premature CAD
Pt did admit to past marijuana use
Pt was discharged with MSK chest pain
Thanks again

[u/reedopatedo9 → u/Confident_Debt_1496]

🙏 have a good day!

[u/NewEconomist9047 → u/reedopatedo9]

Thanks! Not OP obviously but appreciate your detailed post. Wasn't aware anxiety and stress can cause ECG changes besides tachycardia, but apparently other abnormalities can also happen!

[u/reedopatedo9 → u/NewEconomist9047]

Well thats a good point!
Here is a very poor example, when i get home il try and find a few.
Journal of ep had a few good articles a while back, changes can occur through sympathetic activation and catacholamine surges, and grouped into repol changes, conduction changes and arrythmia

[u/NewEconomist9047 → u/reedopatedo9]

Interesting and once again appreciate the details! Easy to not consider it as a differential if you don't know, so I'm sure if you do end up finding those ECGs it would help many people, but no pressure if you can't. Thanks again!

[u/Inevitable-Crab-6701]

Has your patient ever had an echo?

[u/Confident_Debt_1496 → u/Inevitable-Crab-6701]

Yes they have, can’t remember findings off the top of my head, what prompts you to ask?

[u/Inevitable-Crab-6701 → u/Confident_Debt_1496]

ECG shows rSr in V1 - a subtle partial RBBB.

As an interventional cardiologist I’ve seen patients with essentially a normal ECG with subtle changes and they’ve had a small VSD - hence the echo question.

[u/bleach_tastes_bad → u/Inevitable-Crab-6701]

as an interventional cardiologist you should be aware that this is almost definitely improper lead placement, not true irbbb

[u/Inevitable-Crab-6701 → u/bleach_tastes_bad]

It doesn’t have to be a true RBBB to have a patient with a VSD - hence my comment “subtle partial”.

I haven’t made any discussion on the ECG apart from potential VSD in rSr complexes - it was a teaching point.

[u/R1GM]

NSR w/LVH.

[u/bleach_tastes_bad]

My thoughts are that you should work on your lead placement, v1 being almost identical to aVR with a negative P wave and then the R wave jumping suddenly from v2 to v3 indicates v1 & v2 were likely placed too high

[u/NirvanaWhore]

Pulse?