Straining for the elevation

There’s elevation, and there’s elevation.  Sometimes it’s the top of a sand dune.  Sometimes it’s the top of a volcano (like Ecaudor’s Antisana, below).  The dunes are caused by wind (I think?).  The volcano by geologic forces.


When we see elevation on an EKG we tend to think of one cause.  But are there more?

70’s y.o. man with dizziness and shortness of breath

The patient is tachy, the RR interval is a little more than 2 big boxes wide so we’re looking at 130’s or 140’s.  A couple of you were a little skeptical about there being P waves, but if you zoom in on the rhythm strips they’re there.


The PR interval looks reasonable and we see no PR depression.

The QRS is narrow, but a Q wave in III should draw the eye.


Moving on to the ST segments we see right away in the above zoom that there’s an inverted T wave in III.  Looking elsewhere we see a millimeter of ST elevation in V1 and V2.


Does that mean this is a STEMI?  It’s a little odd to see elevation most prominent in V1 and V2, and there isn’t really reciprocal change elsewhere (unless you count the T wave inversion in III which would be much more supportive if it was ST depression).  Is there something else that causes a Q wave in III and T wave inversion in III (and oh by the way an S wave in I?)  Something that could cause Right heart strain and an injury pattern in V1 and V2??  And a marked tachycardia??? If that doesn’t set off alarm bells then the patient’s CT angio should.


The patient has a saddle PE.

The takehome from this EKG?  While ischemia has to be at the top of your differential when you see STE, remember that it’s not the only potential cause.

0 comments on “Straining for the elevation

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: