Elias Hanna, MD, Cardiology

Differential diagnosis: Anterior STEMI with hyperacute ischemic T wave and inferior ST depression versus Hyperkalemia. -However, hyperacute ischemic T waves are wide rather than tall and narrow (see next slide). The narrow-based T waves that pull the ST segment are hyperkalemic T waves (as in this case). -The QRS is wide with a RBBB pattern (rSR’ in V2). This could fit with anterior STEMI (acute RBBB may occur with anterior STEMI) or, in this case, widened QRS due to hyperkalemia -Final diagnosis: Hyperkalemia

Hyperacute ischemic T wave, wide. The patient also has LBBB

Ischemic ST elevation with hyperacute wide T. Note the difference with hyperkalemia

Pull Findings in hyperkalemia: T wave in hyperkalemia is typically tall and narrow, but does not have to be tall (may be just narrow and peaked pulling ST segment). Tall T means > 2 big boxes in the precordial leads or >1 small box in limb leads, or T wave taller than QRS.