Simple STain on the Strain

Sometimes LVH isn't all that simple. The "strain" pattern has been discussed elsewhere on this and other blogs, but this is an example of an atypical, and concerning, ECG:

What's not (so) unusual: 
The ECG reveals a sinus rhythm. The downsloping ST segments and T wave inversions seen in the lateral leads and precordial leads may be expected in the setting of high left ventricular voltage. The pattern of LVH and ST/T wave changes is consistent with, "strain."

What's concerning: 
The ST segment elevation present in aVL and V1-V2 is NOT concave and almost horizontal. This type of ST segment change is consistent with ischemia. Furthermore, it appears in an anatomic distribution. ST segment changes in aVL and V1-V2 suggest anterior or anterior lateral ischemia. Though LifeNET measures the ST segment elevation at less than 2 mm, it is nevertheless cause for concern especially given a "typical" story or history consistent with an acute coronary syndrome.

Bottom line and interpretation:
Carefully evaluate ST segment deviation in all leads. Look for atypical elevation and an anatomic distribution of the ECG changes.
Sinus rhythm, ST segment depression and T wave inversion consistent with strain pattern. ST segment elevation in the anterior precordial leads and aVL suspicious for STEMI.