This ECG is from a 50 yr old male who presented complaining of productive cough and fever for 2 days.
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VAQ Corner A 50 yr old male presents to your Emergency Department complaining of shortness of breath, productive cough and fever. Vital signs: BP 136/78 RR 22 Sats 94% RA Temp 38.8 C (101.8 F) Describe & interpret his ECG
A 67yr old male presents to your Emergency Department complaining of central chest pain for the last 2 hours associated with dysponea and nausea. Vital signs: BP 103/55 RR 22 Sats 95% RA Describe & interpret his ECG ? (50%) Outline your management ? (50%)
ST segment analysis difficult due to baseline wander
Deep symmetrical T wave inversion leads II, III, aVF, V5-6
Interpretation: Without more clinical information on the case including prior medical history, findings on serial ECG's, old ECG's, and result of further investigations post this episode e.g. echo or angio it's difficult to give a clear conclusion to this case and ECG. The broad differentials for the findings on this ECG are:
Structural Heart Disease
Cardiac T-wave Memory
T-wave memory is an interesting phenomenon that could explain the marked T wave changes seen on this ECG. It results in transient T wave changes following a period of abnormal ventricular conduction e.g. ventricular tachycardia, paced rhythms, intermittent bundle branch block or aberrant conduction. There is a recent paper by Vakil that is freely available (linked to below) that contains a nice overview of T-wave memory, proposed mechanisms, and a case example.The deep T wave inversion on this ECG correspond to the leads in which a negative QRS was seen in the patients pre-cardioversion ECG (case here) a finding consistent with T-wave memory. Patient's often require work-up to exclude underlying ischaemia or structural disease but cardiac T-wave memory is a benign and self-resolving condition in itself.
References / Further Reading Article
Vakil K, Gandhi S, Abidi KS, et al. Deep T-Wave Inversions: Cardiac Ischemia or Memory? JCvD 2014;2(2):116-118. Full text here.
Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.
This ECG is from a 70yr old male who presented with chest pain and palpitations. Vital signs: BP 85/64 RR 20 Sats 98% on 10L/min. I don't have any more information on the patient's past medical history or current medication. Check out the comments on our original post here.
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LAD (~ 80deg)
QRS - Prolonged (140ms)
QT - 320ms
Regular Wide Complex Tachycardia
Clinical compromise evidence by chest pain and hypotension
General differential diagnosis are:
SVT with aberrancy
SVT with pre-existing conduction delay
SVT with pre-excitation
Not applicable in this case but don't forget paced rhythms
But what about this ECG. Both of our blog electrophysiologists have reviewed this ECG and feel SVT (likely atrial flutter) with RBBB aberrancy is the likely diagnosis. The QRS activation pattern of rapid activation till QRS peak followed by slower activation is classic for RBBB aberrancy. The combination of RBBB and LAHD (left axis deviation) means the SVT exit is the left posterior fascicle (left mid to basal LV), if this was VT it would be a fascicular VT. I'd encourage our reader to check out the links below for more on VT vs SVT with aberrancy and also on fascicular VT. What happened ? Well the patient underwent DC cardioversion in the Emergency Department and his post cardioversion ECG can be found as next week's case here.