A 74-Year-Old Man with Epigastric Pain

Differential Diagnosis

• Anterior STEMI
• Right bundle branch block
• Left axis deviation
• Brugada syndrome
• Wellen’s syndrome

Diagnosis
The patient was diagnosed with a left axis deviation. The ECG reveals normal sinus rhythm with an axis of -49, confirming left axis deviation (LAD). There are also some ST depressions laterally (I, aVL, V5, V6) which could indicate ischemia.

Learnings/What to Look for:

• The normal axis of an ECG is -30 to +90
• LAD is defined as -30 to -90
• Causes of left axis deviation may include idiopathic/normal variation, left ventricular hypertrophy, inferior MI, paced rhythm, left anterior hemiblock/left bundle branch block (LBBB), preexcitation such as Wolff-Parkinson-White (WPW), and congenital heart disease

Pearls for Initial Management and Considerations for Transfer

• Compare with a previous ECG, if available
• Though this finding is often benign, the history will help to direct consideration of more serious etiologies
• Consideration of ischemia/infarction, new-onset LBBB, or symptomatic preexcitation requires transfer and emergent management, though most of the time a finding of LAD will be a normal variation and often present on previous tracings