ECG of the Week – 5th September 2016 – Interpretation

The following ECG is from a 60 yr old female who presented complaining of central chest pain. Background of hypertension and a prior smoking history.




Click to enlarge



Rate:
 

  • 84 bpm

Rhythm:

  • Regular 
  • Sinus rhythm 

Axis:

  • Normal

Intervals:

  • PR – Normal (~160ms)
  • QRS – Normal (90ms)
  • QT – 400ms (QTc Bazette 435 ms)

Segments:

  • ST elevation leads aVL (<1mm) I (2nd & 3rd complexes <1mm)
  • ST depression leads II, III, aVF
 Additional:
  • Up-sloping ST segment V6
  • T wave inversion leads III, aVR, V1
Interpretation:
  • High lateral changes suspicious for ACS


What happened ?

Following discussion with the cardiology team the patient was transferred for primary angioplasty given on-going chest pain and progressive ECG features.

Coronary angiogram showed:
  • LM – Normal
  • Cx – Dominant with irregularities
  • LAD & RCA – irregularities
  • LV gram – Apical Hypokinesis

Subsequent echo showed:

  • Normal LV size and thickness.
  • Hypokinesis of mid to apical anterolateral, anterior and inferior lateral regions with normal systolic function.

Given echo and angiogram findings the patient was diagnosed with Takotsubo cardiomyopathy. She was commenced on beta-blocker therapy and discharge with 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 – 29th August 2016 – Interpretation

This ECG is from a 71 yr old male who presented complaining of central chest pain. He has a history of embolic CVA a year prior and prior MI with stenting.



Click to enlarge

Rate:

  • 66

Rhythm:

  • Regular
  • Sinus rhythm

Axis:

  • Normal

Intervals:

  • PR – Normal (~180ms)
  • QRS – Prolonged (200ms)
  • QT – 400ms (QTc Bazette 380-400 ms)

Segments / Additional:

  • LBBB
  • Discordant ST segment change with appropriate magnitude
    • See the Life in the Fast Lane post and the Smith paper below for an explanation of ‘excessive’ discordance
  • Lead V3 looks concerning for ACS
    • The initial R wave is a little large than usually seen in LBB but may reflect poor lead placement
    • Given the principally negative voltage of the QRS I would have expected more ST elevation rather than a neutral / subtley depressed ST segment.
    • There isn’t enough ST elevation to make this lead Sgarbossa positive but I’d be closely looking at serial ECG’s for change

What happened ?

The patient was admitted under cardiology and coronary angiography showed:

  • Distal LMCA: 60-70% stenosis
  • Proximal LAD: 60-70% stenosis
  • Ostial 1st diagonal: 70% stenosis
  • Proximal Cx: 80% stenosis
  • Mid-RCA: 90% stenosis

The patient then underwent CABG for treatment of his multi-vessel disease.

Sgarbossa Criteria

I’m not going to reinvent the wheel here regarding Sgarbossa and the modified Sgarbossa criteria as there are several great reviews listed below:


References / Further Reading

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 – 22nd August 2016 – Interpretation

This ECG is from a 20 yr old female who presented following an episode of palpitations with associated chest pain and dysponea.



Click to enlarge

Rate:

  • 60

Rhythm:

  • Sinus arrhythmia

Axis:

  • Normal

Intervals:

  • PR – Short (~100ms)
  • QRS – Prolonged (120-130ms)
  • QT – 440ms (QTc Bazette 440 ms)

Segments:

  • ST elevation leads III, aVF <1mm with flat morphology

Additional:

  • Delta waves leads I, V1-4
  • Pseudo right ventricular hypertrophy secondary to pre-excitation rather than actual chamber enlargement with the following ECG features:
    • Dominant R wave leads V1-6
    • R/S ratio >1 in lead V1
    • T wave inversion leads aVL, V1-3

Interpretation:

  • Wolff-Parkinson-White Syndrome
    • Left posterior / left posterolateral accessory pathway using Arruda algorithm

What happened ?

The patient had known pre-excitation and had been non-compliant with beta-blocker and sodium-channel blocker therapy. The patient was admitted for telemetry and re-instigation of anti-arrhythmic agents prior to ablation consideration / planning.

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.