ECG of the Week – 24th April 2017

The following ECGs are from a 28 yr old female who presented with abrupt onset of chest pain. No relevant past medical history with a positive family history of cardiac disease. The 1st ECG was performed during an episode of pain and the 2nd when the patient was pain-free.

Chest pain ECG
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Pain-free ECG
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Things to think about
  • What are the key ECG findings ?
  • What are the causes for these findings ?

ECG of the Week – 17th April 2017 – Interpretation

This ECG is from a 79yr old male who presented to the Emergency Department with central abdominal pain secondary to an incarcerated hernia. A pre-op ECG was performed and is below.



Click to enlarge

Rate:

  • 66 bpm
    Rhythm:
    • Regular
    • Ventricular paced rhythm
    • Pacing spikes best seen in lead V2
    • Evidence of possible native atrial activity
      Axis:
      • Normal
      Intervals:
      • QRS - Prolonged (160ms)
      Segments / Additional:
      • Typical LBBB morphology
        • Discordant ST / T wave changes
        • Magnitude of ST change is appropriate for QRS voltages 
      Interpretation:
      • Ventricular paced rhythm
        • Nil features to suggest pacemaker problem
        • 100% Capture
        • Nil evidence of sensing failure
        • Sgarbossa / Modified Sgarbossa negative
      The pre-operative assessment of a the patient with an implantable device is outside the scope of Emergency Medicine practice but the following articles have a good overview of how to approach the peri-operative management of patient's with pacemakers:
        
      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 – 10th April – Interpretation

      These ECG's are from a 75yr old with a history of prior STEMI, T2DM and cardiomyopathy (EF 25%). He presented with acute chest pain, nausea and diaphoresis.




      ECG on acute presentation
      Click to enlarge
      Key features:

      • Sinus rhythm, rate ~66 bpm
      • Left axis deviation
      • RBBB
        • Increased QRS widening compared with old ECG below
        • Completion of RBBB compared with old ECG
      • ST Elevation
        • Lead III 1mm 
        • Lead aVF ~1mm
        • Lead II - up-sloping ST
        • All new compared with old ECG
      • ST Depression
        • Leads V1-3, aVL
        • All new compared with old ECG
      • Hyperacute T waves inferolateral leads
        • All new compared with old ECG
      • Deep Q wave leads III, aVF
        • Old changes but higher voltage ? positional vs interval change




      ECG from 2 years prior
      Click to enlarge
      Key features:

      • Sinus rhythm, rate ~78 bpm
      • Left axis deviation
      • Narrow QRS
      • High right precordial voltages
      • Deep Q waves in leads III, aVF
      • Single PVC

      Interpretation:

      • Acute inferior STEMI on a background of prior inferior AMI
      Note the acute differences in ST segment and T wave morphology between the acute presentation ECG and an old ECG.

      What happened ?

      The patient was taken for urgent angiography which showed:

      • LMCA: Minor irregularities
      • LAD: Long segment diffuse disease
      • Cx: Patent stent, distal 70% stenosis
      • RCA: Dominant vessel. Proximal occlusion of PLV branch --> stented
      The patient made an uneventful recovery and was discharge with out-patient cardiology 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 – 10th April

      These ECG's are from a 75yr old with a history of prior STEMI, T2DM and cardiomyopathy (EF 25%). He presented with acute chest pain, nausea and diaphoresis.




      ECG on acute presentation
      Click to enlarge

      ECG from 2 years prior
      Click to enlarge


      Things to think about

      • What are the key ECG findings ?
      • How would you manage this patient ?
      • What would you have done without the old ECG ?