A 54-year-old diabetic man is in his family doctor’s office. One month ago he started complaining of dyspnea and weakness on walking quickly to a bus-stop two short blocks from his home. Previously he did regular moderate exercise without symptoms:

• Sinus bradycardia, 56/min
• Anterior myocardial infarction, age undetermined
• T wave abnormality, consider anterior ischemia
• Minimal voltage criteria for left ventricular hypertrophy

This patient had previously had a normal ECG. The present tracing shows changes of an anterior infarct (tiny R waves that decrease in voltage from V1 to V4).

The negative T waves in V1 to V5 are compatible with ischemia, however, after a myocardial infarction there may be T wave abnormalities in the leads that show the QRS changes of infarction   even in patients who are stable and asymptomatic and in whom tests (such as stress myocardial perfusion studies) do not demonstrate evidence of ischemia on exertion.

The significance of T wave abnormalities on the area of a previous infaction should, therefore, be assessed on   the basis of the clinical information. In this case the patient has symptoms that suggest that he has indeed ischemia. Further investigation and treatment are required.

The R wave in aVL measures 12 mm. There are no other signs of LVH in the other leads. This justifies the statement: “minimal voltage criteria for left ventricular hypertrophy”.