ECG Case 058

Main Abnormalities

This ECG shows changes consistent with an old anterolateral infarction — the so-called left ventricular aneurysm pattern.

• ST elevation in V1-3 associated with deep Q waves (= LV aneurysm morphology).
• Pathological Q waves also seen in I, aVL and V4.
• Poor R wave progression (= R wave height < 3 mm in V3).
• Biphasic / inverted T waves in V1-5, I and aVL.

The LV aneurysm pattern refers to the combination of residual ST elevation, deep Q waves and inverted or biphasic T waves seen in patients following an acute myocardial infarction. This ECG pattern is associated with transmural scarring and paradoxical movement of the LV on  wall on echocardiography.

Around 60% of patients with anterior STEMI develop some degree of chronic ST elevation on their ECG, which can cause diagnostic confusion.

If these patients present with chest pain, the safest approach is to take serial ECGs looking for signs of evolving STEMI such as evolving ST elevation or pseudo-normalisation of T waves.