Pediatric Chest Pain

This is an EKG of a 15 year old female athlete who complained of chest pain which resolved upon medic unit arrival. What do you make of this?

Here's a closer look at some of the lateral leads... 

Looking only at this EKG, here's what I see from the top down: 

• HR 57 - Bradycardia
• PR 128 ms - Sinus Bradycardia
• QRS 76 ms - No bundle branch block
• QTc 406 ms - Within the normal range of 280-430 ms. Also, going by the general rule of the QT being half the R-R, the QT also appears normal in range.
• QRS Axis 98 degrees - Right axis deviation (a normal variant in pediatrics) confirmed by the negative complex in lead I, and positive complex in both II and III.

I See All Leads

• Inferior: ST elevation in II and aVF
• Septal: T wave inversion
• Anterior: ST elevation
• Lateral: ST elevation

So, what about this ST elevation? Are we looking at acute infarction?

One thing that may help is to ask, is the ST elevation (STE) concave or convex. Concave STE, sometimes referred to as "Smiley Face" STE and can be more likely associated with more benign causes of STE.

Non-concave STE is often more likely to be malicious and more serious, indicating acute infarction.

Now this is not a 100% sensitive test. An MI can certainly present with concave STE- especially early on in it's development. But it all becomes part of the picture in accordance with reciprocal changes and the overall patient presentation.

Let's talk about STEMI imitators...

I know of 6 main STEMI imitators
(please add to the list if you know more).

1. Ventricular Rhythms
2. Paced Rhythms
3. Left Bundle Branch Block
4. Pericarditis
5. Left Ventricular Hypertrophy
6. Early Repolarization

Ventricular Rhythms, Paced Rhythms and Left Bundle Branch Blocks

All these can fall under the Ventricular Rhythm category. These are fairly simple to identify given the wide QRS complex associated with them and since we're all fairly familiar with these, I'll move on down the list.

Pericarditis

Typically noted with diffuse ST elevation accompanied by PR depression.

LVH


Can be identified by adding the QRS height of V1 or V2 to the depth of V5 or V6. Greater than 35 mm indicates the presence of LVH.

Early Repolarization

Common in young athletes, early repolarization has long been considered innocent. This "fish hook" appearance is common with Early Repol. and is usually most pronounced in the anterior leads. Recent studies are showing that repolarization abnormalities like this can be associated with sudden cardiac arrest or recurrent VF.

To me, this EKG most resembles the pattern found with early repolarization. With the concave appearance of the STE, no reciprocal changes, I would lean toward the likelyhood that this STE is due to early repol and not acute ischemia. That being said, this EKG is only a small piece of the puzzle and should be considered among all the other findings of an assessment and history.

I'll try to update this post when I find out the outcome of this call. Until then, what are your thoughts on the matter?