DSAE STEMI Review, Mod 2: LVH as a Mimic

The criteria of LVH have been previously discussed in the past slide.  These criteria reflect the measurement of the voltage of the R of S-wave in certain leads.  Also the age must be greater than 35 years.

It is important to take note that another common characteristic of LVH will often (but certainly not always) appear in the lateral-highlateral leads (V4, V5, V6, I, avL).  This is best shown by example in the tracing below.  You will notice that the ECG certainly satisfies the criterion for LVH (R+S > 35 mm).  In addition, the student should take note that there is ST-segment depression and T-wave inversion in some of the lateral leads.  You should also note that the ST-segment depression assumes a characteristic ramp-like depression and the T-wave inversion is asymmetrical, ie. is not reproduced by rotation around the rotational axis.  This is clearly an important observation since this is now added to our differential explanation for ST-segment depression (along with ischemia, acute infarction and reciprocity) and T-wave inversion (along with ishemia, LBBB, RBBB, IVCD).  This pattern is called LVH with ST-T repolarization changes (sometimes referred to as “strain pattern”).

It is also interesting to note that the LVH pattern will often produce Q-waves in V1 and V2 and event V3.  These Q-waves do not represent an old MI but in fact might be simply a part and parcel of the LVH with strain pattern.  This pattern invariably represents a long standing pattern of many months to years.

The provider should also observe that the LVH pattern is often associated with poor R-wave progression and late transition.

Furthermore, one commonly sees ST-segment elevations in Leads V1, V2 and maybe V3.  These ST-segment elevations may be “CONCAVE DOWN” as a part and parcel of the LVH pattern.  Since this does not represent an acute MI pattern necessarily, it is sometimes referred to as a “PSEUDOINFARCTION PATTERN” in Leads V1, V2, V3.

LVH Example tracing


To summarize, it is important to be aware that LVH pattern may demonstrate:

  1.  Pseudoinfarction ST-elevation with ST elevation that is CONCAVE Down and peaked Ts (in leads V1, V2, V3)
  2.  Pseudoinfarction Q-waves, often present in V1, V2, V3
  3.  ST depression and/or T-wave inversion in the lateral-highlateral leads of strain (V6, V5, V4,I,avL)