ECG of the Week – 21st July 2014 – Interpretation

This ECG is from a 50 yr old male who presented complaining of productive cough and fever for 2 days.
Check out the comments on this case in our original post here.





Click to enlarge
Rate:
  • 67 bpm
Rhythm:
  • Regular
  • Sinus Rhythm
Axis:
  • Normal
Intervals:
  • PR - Short (~100ms)
  • QRS - Prolonged (140-160ms)
  • QT - 400ms (QTc Bazette 410 ms)
Segments:
  • ST elevation leads aVR, V1-3
  • ST depression leads I, II, III, V4-6
Additional:
  • Delta wave 
    • Best seen leads I, II, III, aVF, V4-6
  • T wave inversion lead aVL
  • Broad P wave lead II with notching of peak
Interpretation:
  • Wolff-Parkinson-White
    • Anteroseptal pathway
For the variety of ways WPW can influence the ECG please check out this excellent post from Dr Steve Smith here:



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 – 14th July 2014 – Interpretation

This week's ECG is from a 67 yr old male who presents with 2 hours of chest pain with associated dysponea and nausea.
Check out the comments on the original post here.




Click to enlarge
Rate:
  • ~65 bpm
Rhythm:
  • Sinus Arrhythmia
Axis:
  • Normal
Intervals:
  • PR - Normal (~180ms)
  • QRS - Normal (100ms)
  • QT - 360ms (QTc Bazette 375 ms)
Segments:
  • ST Elevation leads I (1mm), II (4-5mm), III (3mm), ,aVF (4mm), V4 (2mm), V5 (2.5mm), V6 (3mm)
  • ST Depression leads aVR, aVL, V1-3
    • Flat ST depression V1-2
Additional:
  • Dominant R wave leads V2-3
Interpretation:

  • Infero-lateral-posterior STEMI

What happened ?

The patient was taken for urgent angiography and PCI which showed:

  • Left main - normal
  • LAD - normal Diagonal branch- 90% occlusion
  • Circumflex - OM1 90% & mid LCx 100% occlusion
  • RCA - mild disease only

The circumflex lesion was stented and subsequent Echo showed:

  • Normal LV size & systolic function
  • Normal RV size & systolic function
  • No valvular dysfunction

The patient made an uneventful in-patient recovery and was discharged for out-patient 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 – 14th July 2014

This week's ECG is from a 67 yr old male who presents with 2 hours of chest pain with associated dysponea and nausea.




Click to enlarge

VAQ Corner

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%)

ECG of the Week – 7th July 2014 – Interpretation

This week's ECG comes from the same patient as last weeks case (ECG of the Week - 30th June). You'll remember we had a 70yr old male who presented with chest pain, palpitations and hypotension. He underwent DC cardioversion and this is his post cardioversion ECG.
Check out the comments on our original post here.


Click to enlarge
Rate:
  • 78
Rhythm:
  • Regular
  • Sinus rhythm
Axis:
  • Normal
Intervals:
  • PR - Normal (~180ms)
  • QRS - Normal (100ms)
  • QT - 320ms (QTc Bazette 370 ms)
Segments:

  • ST Elevation leads V1 & V3 ?? aVF
  • ST Depression leads II, III, aVF, V5-6
  • ST segment analysis difficult due to baseline wander

Additional:

  • 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:

  • Ischemia
  • 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.

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 – 30th June 2014 – Interpretation

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.


Click to enlarge

Rate:
  • 150
Rhythm:
  • Regular
Axis:
  • LAD (~ 80deg)
Intervals:
  • QRS - Prolonged (140ms)
  • QT - 320ms
Additional:

  • RBBB Morphology
    • Typical morphology
Interpretation:

  • Regular Wide Complex Tachycardia
    • Clinical compromise evidence by chest pain and hypotension

General differential diagnosis are:

  • Ventricular Tachycardia
  • 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.


References / Further Reading

Life in the Fast Lane

Academic Life in Emergency Medicine


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