STEMI Mimics: Part 1, Left Ventricular Hypertrophy

STEMI Mimics: Part 1, Left Ventricular Hypertrophy Posted By:
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As advanced practice providers, we are expected to be able to discern dangerous rhythms on the ECG—such as the dreaded ST-segment elevation myocardial infarction (STEMI). Yet, there are a multitude of rhythms that mimic this feared arrhythmia. Why is this important? These STEMI mimics are often mistaken for an acute myocardial infarction on the 12-lead ECG, and thus lead to inappropriate activation of cardiac catheterization lab personnel, as well as inappropriate treatment of patients, when these rhythms are usually benign or demonstrate some other pathology requiring attention geared toward a different treatment or intervention. As alluded to earlier, there are many STEMI mimics, but I will cover the 2 most commonly encountered in a 2-part post.

Most common STEMI mimics:

  • Left ventricular hypertrophy (LVH) - 25%
  • Left bundle branch block - 15%
  • Early repolarization - 12%
  • Right bundle branch block - 5%
  • Ventricular aneurysm - 3%
  • Hyperkalemia - 3%
  • Brugada syndrome - 1%
  • Pericarditis - 1%
  • Osborne (J) waves (hypothermia) - 1%
  • Non-ischemic vasospasm - 1%

LVH is the single most common STEMI mimic. It may or may not exhibit ST changes and can be difficult to determine. LVH is recognized as causing many false-positive cardiac catheterization lab activations. The electrocardiographic diagnostic criteria for LVH are numerous, but poorly sensitive. The most widely used criteria is the Sokolow-Lyon criteria: If the sum of the amplitude of the S in V1 + R in V5/6 >35 mm, LVH is present.

Electrical remodeling of the left ventricle in the setting of hypertrophy causes ST elevation in leads V1-V3, as well as the "strain" pattern. In patients with LVH, this elevation in leads V1-V3 may mimic an anterior STEMI; however, it is understood that the ST elevation seen in a STEMI is usually greater than that seen with LVH. Adding to its complexity, it may not be possible to distinguish LVH with any repolarization abnormality from myocardial ischemia if no previous ECG is available for comparison. Some tips to remember:

  • True anterior STEMI almost never presents in the setting of profound LVH
  • ST segment may be benignly convex

ECG noting LVH

Image courtesy of Benjamin Taylor.
ST elevation (boxes) with noted LVH (arrows). There are inferior/lateral ischemic changes (inverted T-waves). STEMI called; Cardiac catheter was negative.
References
  • Brady WJ, et al. Cause of ST segment abnormality in ED chest pain patients. Am J Emerg Med. 2001;19:25.
  • Birnbaum Y, Alam M. LVH and the diagnosis of STEMI - how should we apply the current guidelines? J Electrocardiol. 2014;47:655.

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Filed under: Cardiometabolic

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