ECG of the Week – 8th September 2014 – Interpretation

This week's ECG is from a 75 yr old female. Past medical history of GORD. She presented complaining of 3 hours of epigastric pain with severe nausea and multiple episodes of vomiting.




Click to enlarge

Rate:
  • 66 bpm
Rhythm:
  • Regular
  • Sinus rhythm
    • Baseline artifact makes P waves difficult to see but best seen in leads V1-3
Axis:
  • Normal
Intervals:
  • PR - Prolonged (280ms)
  • QRS - Normal (80-100ms)
  • QT - 380ms (QTc Bazette 400 ms)
Segments:

  • ST Elevation leads III, aVF (<1mm)
  • Flat ST depression V1-3

Additional:

  • T wave inversion leads I, aVL, aVR, V1-3
  • Prominent T waves leads III, aVF, V6
  • Prominent R wave lead V2

Interpretation:


  • Infero-postero-lateral MI

What happened ?

The patient had posterior leads performed, ECG below:




Posterior leads show clear ST elevation and the eagle-eye'd among you will notice that leads V1-3 are clearly different from the first ECG.

Our local lead set-up means V1-3 on this ECG are certainly leads V4-6 but haven't been labelled as such. 

The patient was transferred for urgent PCI and a lesion was stented. 

Unfortunately the hospital discharge summary doesn't state where the culprit lesion was !!



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 – 8th September 2014

This week's ECG is from a 75 yr old female. Past medical history of GORD. She presented complaining of 3 hours of epigastric pain with severe nausea and multiple episodes of vomiting.




Click to enlarge

VAQ Corner has gone ! Introducing 'Exam Thoughts'

ACEM are changing the structure and format on their Fellowship exam and as such VAQ Corner is no longer relevant for our Australian readers.

In it's place will be 'Exam Thoughs' a selection of quick questions that could accompany this ECG is an exam setting, OSCE, viva, SCE or written format.

So for this ECG:

  • What are the key features of the ECG ?
  • What is your interpretation ?
  • What are your next key clinical steps ?



ECG of the Week – 1st September 2014 – Interpretation

This ECG is from a 68 yr old male. He was 2  months post pacemaker insertion for sinus node dysfunction and presented following an episode of syncope.



Click to enlarge


Rate:
  • Mean ventricular rate 90 bpm
Rhythm:
  • Complexes #1-4 & 6-7 A-V sequential paced
  • Complexes #5 & 8-15 V-paced
Axis:
  • LAD
Intervals:
  • QRS - Prolonged (160-180ms)
Segments:

  • Appropriate discordant ST segment -T wave change
    • Sgarbossa / modified Sgarbossa negative

Additional:

  • Abrupt rate change from complex 8 onwards
    • Rate increases to ~135 bpm
    • Initial rate complexes #1-4 is ~60 bpm
  • Notching in baseline after complex #6 best seen in V1-3
    • ? Native atrial activity ? artefact


Interpretation:


  • Paced rhythm
    • Abrupt acceleration in rate

My thoughts were:

  • ? Rate modulation
    • I don't know how rapid the rate can change as there appears to be no gradual increase in the rate
  • ? Sensor induced tachycardia
  • ? Pacemaker mediated tachycardia

I don't know the cause of the sudden rate change in this patient I have sent the ECG to our blog electrophysiologists and will update the interpretation once I get their thoughts on this ECG.

Clinical correlation may be helpful regarding presence of symptoms, blood pressure, or driving features for tachycardia e.g. fever. I'd be liaising with the patient's cardiologist for more information on the pacemaker settings and also looking to arrange a pacemaker interrogation to see what's going on.

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 – 1st September 2014

This ECG is from a 68 yr old male. He was 2  months post pacemaker insertion for sinus node dysfunction and presented following an episode of syncope.



Click to enlarge


VAQ Corner

A 68 yr old male presents to your Emergency Department following an episode of syncope.
2 months prior he had a pacemaker inserted for Sinus Node Dysfunction.


  • Describe & interpret his ECG

ECG of the Week – 25th August 2014 – Interpretation

This ECG is from a 45 yr old male presenting to the Emergency Department following an episode of chest pain. He was pain  free when this ECG was recorded.

Check out the comments from our original post here.

Click to enlarge

Rate:
  • 60
Rhythm:
  • Sinus arrhythmia
Axis:
  • Normal
Intervals:
  • PR - Short (100ms)
  • QRS - Prolonged (140ms)
  • QT - 400ms (QTc Bazette 400 ms)
Segments:
  • ST Elevation leads aVR, V1-4
  • ST Depression leads I, II, III, aVF, V5-6
Additional:
  • Voltage criteria for LVH
  • Delta waves best seen infero-laterally
Interpretation:

  • Wolff-Parkinson-White Syndrome
    • ST segment changes proportional and discordant to QRS direction
    • Anteroseptal pathway (Arruda Algorithm)

What happened ?

The patient had known WPW and serial ECG's and biomarkers were negative and he was referred for an out-patient provocation test.

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.