Syncope in a Middle-aged Man

Abstract

A man in his 40s with hypertension was brought to the emergency department after becoming unresponsive during descent on a commercial flight. He was alert and oriented with normal heart rate and blood pressure by emergency medical services evaluation and in the emergency department. He had no recollection of the event, with history notable only for more than usual alcohol use the 2 days prior, including drinking just prior to boarding the plane. A 12-lead electrocardiogram (ECG) was obtained (Figure).Question: Based on the ECG findings, what is the most likely diagnosis? InterpretationThe ECG showed normal sinus rhythm with left ventricular hypertrophy (LVH) by the Sokolov-Lyon criteria and likely intra-atrial conduction delay with a biphasic P wave in leads III and aVF. There were 1-to 2-mm ST-segment elevations in leads V 1 to V 3 with 2-to 3-mm ST depressions in leads V 5 to V 6 . There were T-wave inversions (TWIs) in leads I, aVL, II, and aVF and deep inversions in leads V 4 to V 6 .