ECG of the Week – 3rd August 2015

This ECG is from a 50 year old male who presented with 2 hours of typical chest pain on a background of progressive dysponea for the preceding 2 weeks. Past medical history of hypertension, diabetes and hyperlipidaemia. 


Click to enlarge
Things to think about
  • What are the key ECG features ?
  • What would you do with this patient ?



ECG of the Week – 27th July 2015 – Interpretation

This ECG is from a 28 year old female who presented complaining of intermittent pre-syncope and palpitations. She is normally fit & well and is 34 weeks pregnant.
Check out the comments from our original post here.



Click to enlarge
Rate:
  • 78
Rhythm:
  • Regular
Axis:
  • Normal
Intervals:
  • PR - Short (~200ms)
  • QRS - Normal (80ms)
  • QT - 320ms (QTc Bazette 365ms)
Segments:
  • Subtle ST depression leads I, V4-6
 Additional:
  • Voltage criteria LVH
    • S wave V1 + R wave V6 =~38mm

Interpretation:
  • Short pr
    • Could this be Lown-Ganong-Levine ?
  • Voltage criteria for LVH

What happened ?

The patient was admitted for investigation under joint care of cardiologists and obstetricians.
Investigation for PE was normal. Echo showed:
  • Normal left ventricular size with normal wall thickness and normal systolic function.
  • Possible mild dilatation of the right ventricle
    • May be physiological due to stage of pregnancy.
  • Normal right ventricular systolic function.
  • Normal atrial size
  • No significant valvular abnormality
In-patient telemetry revealed no arrhythmia despite the patient complaining of palpitations.
The patient was discharge with on-going obstetric follow-up.

Lown-Ganong-Levine (LGL)

LGL is often grouped with WPW as part of the pre-excitation syndromes the major ECG difference is that LGL has only pr shortening without the QRS changes associated with WPW. The advent of EP studies has resulted in a greater understanding of cardiac conduction and it's role in arrhythmogenesis with the existence of LGL as a clinical entity disputed. It is likely the short pr reflects an extreme of the normal variation and may not play any role in arrhythmogenesis.
This eMedicine article has a great review of LGL an the current evidence around it's existence as a clinical entity:
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 – 27th July 2015

This ECG is from a 28 year old female who presented complaining of intermittent pre-syncope and palpitations. She is normally fit & well and is 34 weeks pregnant.



Click to enlarge

Things to think about

  • What are the key ECG features ?
  • What are your differentials for this patient's presentation & ECG ?
  • How would you investigate this patient ?

ECG of the Week – 20th July 2015 – Interpretation

This ECG is from a 50 year old male who presented with 10 hours of chest pain.
Background history of hypertension and smoking.
Check out the comments from our original post here.



Click to enlarge
Rate:
  • 90 bpm
Rhythm:
  • Sinus Arrhythmia
Axis:
  • Normal
Intervals:
  • PR - Normal (~200ms)
  • QRS - Normal (100ms)
  • QT - 400ms (QTc Bazette 380-400 ms)
Segments:
  • ST Elevation leads V1 (2mm), V2 (2-2.5mm), aVR (1mm)
  • ST Depression II, III, aVF, V5-6
Additional:
  • Voltage criteria LVH
    • S wave V1 + R wave V5 = 24mm + 14mm = 38mm
  • Left Arial Enlargement

    Interpretation:

    • LVH
      • ST changes proportional to S wave voltage
      • ST to S wave ratio <25%
    What happened ?


    In this case the changes due to LVH were thought to represent acute MI and the patient was taken for urgent angio which was essentially normal.


    There are a few nice reviews on LVH and ACS look at decision rules to help distinguish LVH from LVH + acute AMI that I'd recommend:


    Also a number of cases from Dr Smith involving LVH:


    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 – 13th July 2015 – Interpretation

    This ECG is from a 36 year old male who presented to the Emergency Department with 8 hours of right sided chest pain.
    Check out the comments from our original post here.




    Click to enlarge

    Rate:
    • 72
    Rhythm:
    • Regular
    • Sinus rhythm
    Axis:
    • Normal
    Intervals:
    • PR - Short (~100ms)
    • QRS - Pronlonged (110ms)
    • QT - 340ms
    Segments:
    • ST Depression lead aVL, V6
    • ST Elevation leads aVR, V1 (<1mm)
    Additional:
    • Delta wave best seen leads I, V2, V3
    • Notching initial portion QRS leads II, V4-6
    • Marked prominent T wave lead V3
    • Q waves leads III, aVF
    Interpretation:
     
    • Wolff-Parkinson- White
      • Short pr, delta waves & QRS widening
      • Right Lateral Wall AP using Arruda Algorithm
      • Inferior Q waves secondary to AP conduction - "pseudo-infarction"
    • Prominent T wave in lead V3
      • This looked suspicous to me and would have prompted serial ECG's and urgent review of any prior ECGs
     
    What happened ?

    The patient had known WPW at the time of presentation and had a normal stress echo and EST the year prior following an Emergency Department attendance with chest pain.
    Old ECG's were identical to the one shown here and serial ECG's revealed no dynamic changes.
    Serial biomarkers were negative and the patient was discharge with out-patient cardiology follow-up

    A must read post

    I'd encourage all our readers to look at this post from Dr Smith with some great examples of WPW with and without superimposed ischaemia:


    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.