A couple of weeks ago, I mentioned that aVL is a great place to check for reciprocal changes that you might not see in lead I if you are suspicious of an inferior STEMI.

RebelEM have just posted a podcast by Amal Mattu where he takes you through the significance of subtle changes in aVR – a lead that it seems many practitioners ignore;

http://rebelem.com/is-st-segment-elevation-in-lead-avr-getting-too-much-respect-with-amal-mattu

(By the way, I think Amal Mattu’s ECG Weekly program is fantastic value !)

aVR does look lonely..

So your patient’s ECG is pretty much ‘normal’, but there’s something not quite right about the look of those T-waves ?

You may well be onto the first, subtle signs that your patient is at the start of their infarct, before S-T segment elevation becomes obvious.

You’ll be doing them a favour by checking out this great post by Justin Bright at EM Docs that steps you through 4 causes of abnormal T-waves;

http://www.emdocs.net/hyperacute-t-waves

Following on from this post where I mentioned that I always look for reciprocity when interpreting an ECG, I’ve been meaning to link to this post for some time.

ECG Medical Training‘s posts are to the point, and this one highlights aVL as a lead that might be overlooked when contemplating reciprocity for inferior STEMI (which you might not see in lead I) ;

http://www.ecgmedicaltraining.com/importance-of-lead-avl-in-stemi-recognition

I’m not one for pattern recognition – I try to stick to a systematic review of the rate, intervals, regularity, origin and then work through the leads, where they physically map to, and look for reciprocity..

This image from LITFL is one of my favourite desktop backgrounds (but I digress);

The team at RebelEM put together great posts, and this highlights that just because the ECG you’re reading doesn’t meet ‘the criteria’ for immediate intervention, it won’t evolve into something that does.

http://rebelem.com/five-ecg-patterns-you-must-know

Fantastic summary;

http://www.tamingthesru.com/blog/grand-rounds/stemi

Especially based on age – Dr. Smith makes some important points here;

http://hqmeded-ecg.blogspot.com.au/2015/09/a-21-year-old-with-chest-pain.html