A 40-something male with epigastric pain

A 40-something male presented with epigastric pain.

An ECG was recorded immediately (time zero):

This was texted to me asking for my opinion.
What do you think?

My answer: Normal variant

He had serial ECGs:

This was recorded at t = 40 minutes:

Subsequently, the patient was diagnosed with cholecystitis.

This was recorded at t = 110 minutes

Notice there is some change from ECG to ECG, but this is not uncommon in these normal variants.

That you cannot entirely rely on the temporal stability of the ECG to diagnose normal variants is, to use a favorite phrase, “Sad!”.

All serial troponins were below the level of detection.

Learning points

How does one recognize one such ECG as ischemic and one as normal variant?  Why are these not Wellens’ waves?

All I can say is that you need to read many many ECGs and get experience and follow up on the outcomes of your interpretations!  There are many cases on this blog that can help you to recognize the difference.

ECGs are like faces: you can easily tell different person’s faces from one another, even though they mostly have the same features: 2 eyes with eyebrows, a nose, cheeks, mouth and lips, etc.  How do you describe the difference?  And yet you know it because of your experience with seeing tens of thousands (or more!) of faces over a lifetime.

Unfortunately, doctors who spend a lifetime learning to recognize such patterns eventually retire or die, and all that knowledge is lost.

We are working to produce a Deep Neural Network ECG algorithm that will learn forever.  It is sad for experts that such a network may one day replace human expertise, but very good for patients.

Here are other examples of normal variants with T-wave inversion that look scary:

Persistent Juvenile T-wave Pattern

8 year-old with report of “syncope and an abnormal ECG”

Here are cases of normal variant ST elevation that looks scary:

High ST Elevation in a Patient with Acute Chest Pain


A 50-something year old with typical chest pain


Several Cases of ST Elevation from Early Repolarization

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