ECG of the Week – 27th July 2015

This ECG is from a 28 year old female who presented complaining of intermittent pre-syncope and palpitations. She is normally fit & well and is 34 weeks pregnant.



Click to enlarge

Things to think about

  • What are the key ECG features ?
  • What are your differentials for this patient's presentation & ECG ?
  • How would you investigate this patient ?

ECG of the Week – 20th July 2015 – Interpretation

This ECG is from a 50 year old male who presented with 10 hours of chest pain.
Background history of hypertension and smoking.
Check out the comments from our original post here.



Click to enlarge
Rate:
  • 90 bpm
Rhythm:
  • Sinus Arrhythmia
Axis:
  • Normal
Intervals:
  • PR - Normal (~200ms)
  • QRS - Normal (100ms)
  • QT - 400ms (QTc Bazette 380-400 ms)
Segments:
  • ST Elevation leads V1 (2mm), V2 (2-2.5mm), aVR (1mm)
  • ST Depression II, III, aVF, V5-6
Additional:
  • Voltage criteria LVH
    • S wave V1 + R wave V5 = 24mm + 14mm = 38mm
  • Left Arial Enlargement

    Interpretation:

    • LVH
      • ST changes proportional to S wave voltage
      • ST to S wave ratio <25%
    What happened ?


    In this case the changes due to LVH were thought to represent acute MI and the patient was taken for urgent angio which was essentially normal.


    There are a few nice reviews on LVH and ACS look at decision rules to help distinguish LVH from LVH + acute AMI that I'd recommend:


    Also a number of cases from Dr Smith involving LVH:


    References / Further Reading

    Life in the Fast Lane
    Textbook
    • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.

    ECG of the Week – 13th July 2015 – Interpretation

    This ECG is from a 36 year old male who presented to the Emergency Department with 8 hours of right sided chest pain.
    Check out the comments from our original post here.




    Click to enlarge

    Rate:
    • 72
    Rhythm:
    • Regular
    • Sinus rhythm
    Axis:
    • Normal
    Intervals:
    • PR - Short (~100ms)
    • QRS - Pronlonged (110ms)
    • QT - 340ms
    Segments:
    • ST Depression lead aVL, V6
    • ST Elevation leads aVR, V1 (<1mm)
    Additional:
    • Delta wave best seen leads I, V2, V3
    • Notching initial portion QRS leads II, V4-6
    • Marked prominent T wave lead V3
    • Q waves leads III, aVF
    Interpretation:
     
    • Wolff-Parkinson- White
      • Short pr, delta waves & QRS widening
      • Right Lateral Wall AP using Arruda Algorithm
      • Inferior Q waves secondary to AP conduction - "pseudo-infarction"
    • Prominent T wave in lead V3
      • This looked suspicous to me and would have prompted serial ECG's and urgent review of any prior ECGs
     
    What happened ?

    The patient had known WPW at the time of presentation and had a normal stress echo and EST the year prior following an Emergency Department attendance with chest pain.
    Old ECG's were identical to the one shown here and serial ECG's revealed no dynamic changes.
    Serial biomarkers were negative and the patient was discharge with out-patient cardiology follow-up

    A must read post

    I'd encourage all our readers to look at this post from Dr Smith with some great examples of WPW with and without superimposed ischaemia:


    References / Further Reading
     
    Life in the Fast Lane
     
    Textbook
    • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.

    ECG of the Week – 6th July 2015 – Interpretation

    The following ECG is from a 65 year old male who was brought to the Emergency Department following an out-of-hospital cardiac arrest. ROSC was achieved pre-hospital following an episode of VT. ON arrival GCS 3, intubated with sats 98%, BP 75 systolic.
    Check out the comments on our original post here.



    Click to enlarge
    Rate:
    • ~84 bpm
    Rhythm:
    • Regular
    Axis:
    • RAD
    Intervals:
    • PR - Prolonged(~220ms)
    • QRS - Normal (80-100ms)
    • QT - 400ms (QTc Bazette 470-480 ms)
    Segments:

    • ST Elevation leads II, III, aVF, V4, V6
      • Unusual ST morphology in inferior leads
    • ST depression lead aVL, V1-3

    Additional:

    • Note complete lead inversion leads I, aVL - negative P/QRS/T
    Interpretation:

    • STEMI
    • Lead malposition
      • Likely V4 & V5 reversed
      • RA / LA limb lead reversal resultant inversion lead I, II/III switched and aVR/aVL switched

    What happened ?

    The patient was taken for urgent PCI which was normal !
    He subsequently went on to have a CT brain which showed an extensive sub-arachnoid haemorrhage.

    There are a number of cases in the literature were sub-arachnoid hemorrhage has been associated with significant ST changes:




    References / Further Reading

    Life in the Fast Lane

    Textbook
    • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.