ST Depression and T-wave inversion in V2 and V3.

A middle aged male dialysis patient was found disorganized and paranoid.  He had no chest pain or dyspnea.

An ECG was recorded.  The clinician was worried about his ECG and showed it to me:

What do you think?

When I saw this ECG, I immediately recognized right ventricular hypertrophy as the cause of the ST depression and T-wave inversion in leads V2 and V3.   In other words, I was certain that this was a chronic finding on the ECG.  The worried clinician stated there are no old ECGs to compare with, and no records.  I remained certain that this was RVH as the findings are classic: Large R-wave in V1, large S-wave in lead I, and typical right precordial ST-T that mimic posterior STEMI. 

If the QRS were normal, and the patient had chest pain, I would have said this was posterior MI, or possibly hypokalemia (see this post: Are These Wellens’ Waves??).

Later, however, we found written records from an outside hospital: 

EKG read:
Normal sinus rhythm
Right ventricular hypertrophy with repolarization abnormality
Nonspecific T wave abnormality
Prolonged QT
Abnormal ECG
No significant change since 05-17-18

Previous echo
Final Impressions:
1. Normal LV size, moderately increased wall thickness, normal global systolic function with an estimated EF of 60 – 65%.
2. Right ventricular cavity size is severely enlarged, global systolic RV function is severely reduced.
3. Severely enlarged right atrium.
4. Mildly enlarged left atrium.
5. Severe tricuspid regurgitation.
6. Severely increased estimated pulmonary pressures by tricuspid regurgitation velocity and right atrial pressure (96 mmHg plus RAP).
7. The inferior vena cava is dilated, respiratory size variation less than 50%, consistent with elevated right atrial pressure.

Learning Point:

Whenever there is abnormal repolarization (abnormal ST-T), look for abnormal depolarization (abnormal QRS).  This might include RVH, LVH, LBBB, RBBB, IVCD, WPW, paced rhythm and more.  If present, assess whether the ST-T abnormalities fit with the abnormal QRS.

2. Learn this pattern, as it is classic for RVH.  Here are some more cases of RVH with ST-T abnormalities:

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