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Ischemia different EKG interpretations

I had two events. I was driving, suddenly I felt very ill/ passing out. Split second... fast forward ambulance, ER etc., dx witjh low Potassium. Finally got a copy of the Ambulsnce EKG - showed it to a heamotologist, general surgeon, pediatric surgeon (friends). All are great experiences Dr. Harvard trained,. 30 years experience, great reputation  etc., All picked out one section and dx ischemia. I showed it to a cardiologist (another top Harvard Professor) who determines it is a completely normal EKG. Went back to other three who were stunned. How can the interpretations be so different. I had a 24 hour holter rate was from 43-143 bpm  all these Dr including cardio are very, very good Doxtors
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Correction I had an echocardiogram which showed LAE at the time
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20748650 tn?1521032211
1. Harvard isn’t that great of a school for Medicine. So if anyone flexed on you because they went to Harvard that’s dumb.

2. Upload ECG to a google drive and share a link if you want an opinion.

3. ECG interpretations differ all the time.

4. The fact that the guy that’s specialized in hearts had a different opinion than 3 guys that are not specialized in hearts is precisely why we have people specialized in hearts.
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Nah, I mean it’s super borderline.

There’s no really definitive answer to this one and I can see where both are coming from.

On one hand people get distracted by the “machine Diagnosis” in the top and tend to agree with it a bit too much. The criteria for any specific conditions in this ekg are JUST BARELY present and in consideration of all the things going on with you at the time (hypokalemia, anxiety, elevated heart rate etc) these could all be shrugged off as a sort of combination of factors coming together to make a non-specific EKG variation. You certainly can’t diagnose anything “bad” with this ekg alone. You would need to have more evidence, an EKG at rest and even a stress test to confirm it.

On the other hand, I will admit that the morphology of those depressions in the left precordials do in fact look “downsloping”; which could signal ischemia. However given that you were hypokalemic these could be an inverted T prominent U situation as well.  

What were your potassium levels at the time of the ECG? Have you had an echo? Have you had a stress test?

As I see it, when it comes to the specific part of the EKG they all saw, there are in fact 3 potential explanations that I would want to investigate. I will list them along with the corresponding test to look at them:

1.  Left Ventricular Hypertrophy (LV “Strain”)- there is no overtly inverted T wave with the lateral lead depressions nor do you meet much of any LVH criteria. HOWEVER there is one *specific* little criteria that says that an S wave > 20mm in V3 may be a sign of LVH. V3 looks like it’s 18mm-20mm precisely and is accompanied by a pattern that looks similar to strain.

I would therefore want to see an Echocardiogram.

2. Ischemia (Demand Ischemia)- as noted these changes could indicate ischemia. But they are too small and there is a lack other ECG “clues” to indicate that this is necessarily a significant problem. It is however possible that with a small amount of mild disease and a lower resting HR that maybe even going up to 120 is enough to stress the heart a bit and create some subtle ECG changes.

I would therefore want to see a new ECG at rest and would want to see an Exercise Stress Test.

ALL THREE of these tests can actually be combined into just ONE: A “Stress Echocardiogram” which will give us an Echo, Stress Test and ECG all in one go! Ample information for this.

3. Metabolic Causes and Electrolyte Abnormalities- There is a whole slew of different conditions, illnesses, chemical imbalances and such which can cause some ECG changes similar to this, too many to just rattle off from the top of my head without missing any. I will say that One of these is Hypokalemia!

I would therefore also want to run a sort of “standard” panel of blood tests:

CMP, CBC and Cardiac Panel
Thank you for your time and very thorough response.  I greatly appreciate your answer and will follow up on your suggestions  of a cardio stress test and a cardio panel.
Potassium levels? My potassium level was 2.8 a time of EKG
Echo? I had an echocardiogram which was normal
Stress test ? No, I have not had a stress test
ECG at rest? I have had a 24 hour EKG rate 43- 143. The 43 was around 7am typically a time I am up at.
I had a 30 day ECG dx with tachycardia, no brachycardia triggered  which triggers below 140
Standard blood test/ CBC  - all normal
No cardio panel was ordered.
Thank you again,  wish that  all Doctors were as thorough as you.

Correction bradycardia on the ekg is triggered with a rate below 40. Not sure if this is relevant in this situation  the ecg report is a paper copy of abnormal  findings which is reviewed by nurses / techs. Their findings are passed along to a cardiologist.
I looked through an ecg from the ER on this date and it noted LAE consider biatrial  enlargement.? Is this related to any three of the scenarios  above? Another test another date  (interpreted by a cardio tech - who  watched the heart pumping while using a wand to scan??) was read as normal.  
Nice work! A top cardiologistal at Beth Israel and a full professor at Harvard (Z...) reviewed  and came back with this!
Reviewed recent EKG finding of LVH. Will proceed with echo to
eval for any abnormalities.
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