ECG of the Week – 23rd March 2015

This ECG is from a 35 yr old male who presented to the Emergency Department following an episode of exertional syncope. He has 1 previous episode of syncope several years prior without investigation. Otherwise he is fit & well with no relevant family history.



Click to enlarge


Things to think about

  • What are the key features on the ECG ?
  • What are your differentials for these features ?
  • What investigations would you consider ?

ECG of the Week – 16th March 2015 – Interpretation

This ECG series is from a 45 yr old male who was undergoing an out-patient exercise stress test (EST) for investigation of chest pain. 
The first ECG is pre-EST. The second ECG was performed when the patient became pre-syncopal during EST. The third ECG was taken 2 minutes after the second ECG and the fourth ECG was performed a further 2 minutes later. The patient was immediately transported to the Emergency Department were he was pain free and ECG was comparable with his pre-EST ECG.
Check out the comments on our original post here.




ECG 1 - Pre-EST
Click to enlarge
ECG 1 - Pre-EST

Rate:
  • 72 bpm
Rhythm:
  • Regular
  • Sinus Rhythm
Axis:
  • Normal
Intervals:
  • PR - Normal (160ms)
  • QRS - Normal (80ms)
  • QT - 340ms (QTc Bazette ~375 ms)
Additional:
  • Flat T wave aVL
Interpretation:
  • Normal ECG
  • Note the normal QTc in light of what happened next

ECG 2 - During EST patient complained of pre-syncope
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ECG 2 - During EST patient complained of pre-syncope

Interpretation:
  • Polymorphic Ventricular Tachycardia (PMVT)
  • Alternating voltage direction and amplitude
  • Given the absence of preceeding QTc prolongation this is not Torsades de Pointes (TdP)
  • Remember the commonest cause of PMVT is myocardial ischemia
  • TdP is a specific form of PMVT seen in the setting of QT prolongation, acquired or congenital.




ECG 3 - 2 Minutes after ECG above. Nil ALS intervention required.
Click to enlarge
ECG 3 - 2 mins after ECG 2

Rate:
  • 96 bpm
Rhythm:
  • Regular
  • Sinus Rhythm
Axis:
  • Normal
Intervals:
  • PR - Normal (140ms)
  • QRS - Normal (100ms)
  • QT - 300ms (QTc Bazette 380 ms)
Segments:
  • ST Elevation leads I(2mm), aVL(3mm), V1(<1mm)V2(3mm)V3(4mm),V4(5mm), V6(<1mm)
  • ST Depression leads II, III, aVF, aVR
Additional:
  • Abnormal R wave progression across leads V4 to V6 - Likely V5 position is incorrect
Interpretation:
  • Anterolateral STEMI


ECG 4 - 2 minutes after ECG 3. Patient pain free.
Click to enlarge
ECG 4 - 2 mins after ECG 3

Rate:
  • 84 bpm
Rhythm:
  • Regular
  • Sinus rhythm
Axis:
  • Normal
Intervals:
  • PR - Normal (~180ms)
  • QRS - Normal (100ms)
  • QT - 320ms (QTc Bazette 380 ms)
Segments:

  • ST Elevation leads (<1mm), aVL(1mm), V2(<1mm) 
    • Significantly reduced compared with ECG 3
  • ST Depression leads II, III, aVF, aVR
    • Significantly reduced compared with ECG 3

Additional:
  • Hyperacute T waves in leads V2-4
  • Abnormal R wave progression across leads V4 to V6 - Likely V5 position is incorrect
Interpretation:

  • Dynamic resolution of ST segment changes ? unstable plaque vs vasospasm
  • Given prior ECGs impending anterolateral STEMI with high risk of arrhythmogenic death

What happened ?

Immediate liaison with interventional cardiology commenced ticagrelor / aspirin / heparin loading and patient was taken for urgent angio which showed:

  • LMA – Normal
  • LAD – 50% Stenosis
  • Cx – Normal
  • RCA – Normal
  • LV gram – Normal


He had PCI + DES to proximal LAD lesion. Peak troponin only 0.25 (lab normal <0.05).

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 – 16th March 2015

This ECG series is from a 45 yr old male who was undergoing an out-patient exercise stress test (EST) for investigation of chest pain. 
The first ECG is pre-EST. The second ECG was performed when the patient became pre-syncopal during EST. The third ECG was taken 2 minutes after the second ECG and the fourth ECG was performed a further 2 minutes later. The patient was immediately transported to the Emergency Department were he was pain free and ECG was comparable with his pre-EST ECG.




ECG 1 - Pre-EST
Click to enlarge

ECG 2 - During EST patient complained of pre-syncope
Click to enlarge

ECG 3 - 2 Minutes after ECG above. Nil ALS intervention required.
Click to enlarge

ECG 4 - 2 minutes after ECG 3. Patient pain free.
Click to enlarge
Things to think about

  • What are the key features on each of the ECG's above ?
  • What would you Emergency Department management be ?
  • What would you do next ?

ECG of the Week – 9th March 2015 – Interpretation

This ECG is from a 70 yr old female who was referred into the Emergency Department with a 1 week history of abdominal pain and altered bowel habit. An out-patient CT scan showed diverticulitis complicated by local perforation. 
She had a past medical history of IHD (CABG and stents), hypertension and type 2 diabetes. During her initial assessment she complained of chest pain which lasted approximately 5 minutes and resolved spontaneously. 
The first of the ECG's below was taken during the episode of chest pain with the second performed ~ 5 minutes later once the patient was pain free.
Check out the comments on our original post here.


ECG 1
Patient complained of chest pain
Click to enlarge
Rate:
  • 96 bpm
Rhythm:
  • Regular
  • Sinus rhythm
Axis:
  • Normal
Intervals:
  • PR - Prolonged (~220ms)
  • QRS - Normal (100ms)
  • QT - 280ms (QTc Bazette 380 ms)
Segments:

  • ST Elevation lead aVR (~1.5mm)
  • ST Depression leads I, II, aVF, V3-6

Additional:

  • T wave inversion leads I, II, III, aVF, V3-6
  • Flat T wave lead aVL

Interpretation:

Diffuse ST segment change with elevation in aVR in the setting of chest pain 
Not a traditional STEMI but should prompt major concern for severe left main or LAD stenosis. However It is not specific for this and can be send with sub-endocardial ischaemia or severe triple vessel disease.In this patient with a known intra-abdominal perforation the differentials include both sub-endocardial demand ischaemia from concurrent illness but given the history of known IHD could also indicate active ACS.

ECG 2
Patient now pain free
Click to enlarge
Rate:
  • 72 bpm
Rhythm:
  • Regular
  • Sinus rhythm
  • Single PVC (Complex #2)
Axis:
  • Normal
Intervals:
  • PR - Prolonged (~220ms)
  • QRS - Normal (100ms)
  • QT - 380ms (QTc Bazette 415 ms)
Segments:
  • ST Elevation lead aVR - subtle and significantly less than ECG a
  • ST Depression leads I, II, aVF, V3-6  - subtle and significantly less than ECG a
Additional:

  • Flat T wave lead aVL

Interpretation:

  • Dynamic ST / T-wave changes improved compared with previous ECG

What happened ?

On discussion with the patient it became apparent they's been having unstable angina symptoms for several weeks. A prior angiogram from 18 months previous showed a left main severe distal stenosis (90%) with patent stents and vein grafts.
We got an urgent surgical and cardiological opinion as the combination of ACS and intra-abdominal perforation posed a significant management challenge. The patient received urgent broad-spectrum antibiotic cover and was commenced on heparin with single anti-platelet therapy due to the potential need for surgical intervention. Unfortunately the patient failed conservative treatment with worsening abdominal pain and underwent a laparotomy / washout / resection but suffered a post-procedural cardiac arrest.

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 – 9th March 2015

This ECG is from a 70 yr old female who was referred into the Emergency Department with a 1 week history of abdominal pain and altered bowel habit. An out-patient CT scan showed diverticulitis complicated by local perforation. 
She hah a past medical history of IHD (CABG and stents), hypertension and type 2 diabetes. During her initial assessment she complained of chest pain which lasted approximately 5 minutes and resolved spontaneously. 
The first of the ECG's below was taken during the episode of chest pain with the second performed ~ 5 minutes later once the patient was pain free.




ECG 1
Patient complained of chest pain
Click to enlarge

ECG 2
Patient now pain free
Click to enlarge
Things to think about


  • What are the key features on each of the ECGs ?
  • What additional information would you want from the patient ?
  • How does this affect your management of this case ?


ECG of the Week – 2nd March 2015 – Interpretation

These ECG's are from a 20 yr old female who presented to the Emergency Department following an episode of chest pain. At review she was pain free and all vital signs were normal. Her serial ECG's are below, there is ~30 mins between each ECG.
Check out the extensive comments on our original post here.


ECG 1
Click to enlarge
Rate:
  • ~66 bpm
Rhythm:
  • Regular
  • Sinus rhythm
Axis:
  • Normal
Intervals:
  • PR - Short (100ms)
  • QRS - Prolonged (140-160 ms)
  • QT - 440ms (QTc Bazette 460 ms)
Segments:

  • ST Elevation lead avR
  • ST Depression leads I, II, aVL, aVF, V5-6

Additional:

  • T wave inversion lead III
  • Delta waves best seen in lateral precordial leads

Interpretation:

  • Wolff-Parkinson-White
    • Type B Pattern
    • AP location right posterior or postero-lateral - thanks Adrian :-)
    • The QRS prolongation, QRS morphology and ST segment changes are all due to pre-excitation.

ECG 2
Click to enlarge
Rate:
  • ~72 bpm
Rhythm:
  • Regular
  • Sinus rhythm
Axis:
  • Normal
Intervals:
  • PR - Normal (~200ms)
  • QRS - Prolonged (120ms)
  • QT - 360ms (QTc Bazette 395 ms)
Additional:

  • RBBB Pattern
  • Deep T inversion leads III, V1-3

Interpretation:

  • Loss of accessory pathway conduction
  • Resolution of pre-excitation features
    • PR now normal
    • QRS narrower
    • No delta waves
    • Change in QRS morphology

But what about the T waves ?

The most striking thing to my eye regarding th e second ECG is the relative depth of the T-waves. They look deeper than one would expect from the RBBB alone.
There is a very broad range of potential causes of such T-wave changes including ischaemia, cardiomyopathy, myocarditis, raised ICP, PE and hyperventilation.
There is also another cause of T-wave change that is very likely in this case which is 'Cardiac T-wave memory' this occurs after a period of abnormal ventricular depolarisation e.g. paced rhythm, VT, SVT with aberrancy and pre-excitation. 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-excited ECG. 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.
  •  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.

We’ve had some cases on the blog before with Cardiac T-wave memory:

Thanks to Adrian and Jason for sharing more resources and further reading on T-wave memory, links below:

What happened ?

Well our patient had a negative troponin and D-dimer with a normal chest x-ray. Her pain was felt to be benign in origin. She was reviewed by cardiology in light of her pre-excitation and out-patient follow-up arranged.

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.