ECG of the Week – 18th April 2016 – Interpretation

The following ECG is from an 84 yr old male who presented with chest pain and dizziness. He had a dual chamber pacemaker in-situ inserted for symptomatic bradycardia.

 

Click to enlarge

Rate:
  • Mean ventricular rate 78 bpm
Rhythm:
  • Nil p waves visible
  • Bigemny
    • V-paced complex followed by premature ventricular complex
V-Paced Complexes (#2,4,6,8,10,12)


Axis:
  • LAD
Intervals:
  • QRS - Prolonged (150ms)
Segments:
  • Appropriate discordant ST segment change
    • Note ST depression in V2 as mentioned in comments but this is discordant to positive QRS (not typical LBBB morphology) and as such should be considered Sgarbossa negative
Premature Ventricular Complexes (#1,3,5,7,9,11,13)


Axis:
  • Normal
Intervals:
  • QRS - Prolonged (130ms)
Segments:
  • Discordant ST / T wave changes

Interpretation:
  • V-paced rhythm with bigemny
  • Underlying sinus node dysfunction - nil native p waves
What happened ?

Despite a mean ventricular rate the patient's pulse rate was only ~40 bpm, i.e. the PVC's were not resulting in 'mechanical' capture. 
The patient had minor electrolyte abnormalities corrected and rate modulating drugs were reduced with resultant decrease in PVC frequency and increased mechanical pulse rate.
Pacemaker interrogation revealed no setting issues and serial troponins were negative.
The patient was discharged with ongoing cardiology follow-up.

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 – 11th April 2016 – Interpretation

This ECG is from a 52 yr old male presenting with 1 hour of central chest pain.


Click to enlarge



Rate:
  • 60 bpm
Rhythm:
  • Regular
  • Sinus rhythm
Axis:
  • Normal
Intervals:
  • PR - Normal (~180ms)
  • QRS - Normal (100ms)
Segments:

  • ST Elevation II (2.5mm), III (3.5mm), aVF (3mm)
  • ST Depression leads I, aVR, aVL, V2, V5-6

Additional:

  • T inversion I, aVL, V1-2

Interpretation:

  • Inferior STEMI

What happened ?

The patient was taken for urgent angiography which showed:

  • RCA: Critical mid stenosis
  • LAD: 80% stenosis
  • LCx: 70% stenosis

Two drug eluting stents were inserted to the RCA and the patient made an uneventful acute recovery with a planned elective angio for further management of the LAD and LCx lesions.

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.