ECG of the Week – 29th June 2015

This week's ECG case is from an 83yr old male who presented to the Emergency Department with several days of atypical chest pain with negative serial biomarkers. He had no relevant past medical history and was on no medication. The first ECG was taken on arrival to the Emergency Department the second ECG was perform when it was noted his heart rate has decreased suddenly. The patient remained asymptomatic during this period with normal conscious level, normal blood pressure and no chest pain or dysponea.



ECG on arrival to the ED
Click to enlarge

ECG with heart rate change
Click to enlarge


Things to think about

  • What are the key features seen on these ECG's ?
  • What historic / symptomatic features would it be important to establish in this patient ?
  • What would you do with him ?

ECG of the Week – 29th June 2015

This week's ECG case is from an 83yr old male who presented to the Emergency Department with several days of atypical chest pain with negative serial biomarkers. He had no relevant past medical history and was on no medication. The first ECG was taken on arrival to the Emergency Department the second ECG was perform when it was noted his heart rate has decreased suddenly. The patient remained asymptomatic during this period with normal conscious level, normal blood pressure and no chest pain or dysponea.



ECG on arrival to the ED
Click to enlarge

ECG with heart rate change
Click to enlarge


Things to think about

  • What are the key features seen on these ECG's ?
  • What historic / symptomatic features would it be important to establish in this patient ?
  • What would you do with him ?

ECG of the Week – 22nd June 2015 – Interpretation

This ECG is from a 75 year old female who presented with 1 hour of central chest pain.
She had recently been hospitalized for a NSTEMI and had 2 drug-eluting stents inserted to her mid RCA.
Check out the comments from our original post here.

Click to enlarge
Rate:
  • ~66 bpm
Rhythm:
  • Regular
  • Likely sinus although P waves are difficult to see
Axis:
  • Normal
Intervals:
  • QRS - Normal (100ms)
  • QT - 400ms (QTc Bazette 380-400 ms)
Segments:

  • Marked ST Elevation leads II, III, aVF, V1, V2-6
  • ST Depression leads I, aVL

Interpretation:

  • Inferior STEMI
  • Likely RV involvement given STE III>II and STE in V1
  • Antero-lateral ST elevation


What happened ?

The patient was taken for emergency coronary angiogram and PCI which showed:

  • Heavy thrombus burden in the RCA stent

The patient made an uneventful recovery and had alteration to his anti-platelet medication.

3rd Universal Definition of Myocardial Ischaemia - Classification of MI

I'd recommend anyone dealing with patient's suffering from, or likely to suffer from myocardial ischaemia to have a look at the '3rd Universal Definition of Myocardial Ischaemia'. One interesting section is the classification system for myocardial ischaemia as it acts as a nice reminder that not all ischaemia is due to blocked native vessels.

Click to enlarge

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 – 22nd June 2015 – Interpretation

This ECG is from a 75 year old female who presented with 1 hour of central chest pain.
She had recently been hospitalized for a NSTEMI and had 2 drug-eluting stents inserted to her mid RCA.
Check out the comments from our original post here.

Click to enlarge
Rate:
  • ~66 bpm
Rhythm:
  • Regular
  • Likely sinus although P waves are difficult to see
Axis:
  • Normal
Intervals:
  • QRS - Normal (100ms)
  • QT - 400ms (QTc Bazette 380-400 ms)
Segments:

  • Marked ST Elevation leads II, III, aVF, V1, V2-6
  • ST Depression leads I, aVL

Interpretation:

  • Inferior STEMI
  • Likely RV involvement given STE III>II and STE in V1
  • Antero-lateral ST elevation


What happened ?

The patient was taken for emergency coronary angiogram and PCI which showed:

  • Heavy thrombus burden in the RCA stent

The patient made an uneventful recovery and had alteration to his anti-platelet medication.

3rd Universal Definition of Myocardial Ischaemia - Classification of MI

I'd recommend anyone dealing with patient's suffering from, or likely to suffer from myocardial ischaemia to have a look at the '3rd Universal Definition of Myocardial Ischaemia'. One interesting section is the classification system for myocardial ischaemia as it acts as a nice reminder that not all ischaemia is due to blocked native vessels.

Click to enlarge

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 – 22nd June 2015

This ECG is from a 75 year old female who presented with 1 hour of central chest pain.
She had recently been hospitalized for a NSTEMI and had 2 drug-eluting stents inserted to her mid RCA.



Click to enlarge
Things to think about

  • What are the key features of the ECG ?
  • What type of myocardial infarction is this likely to be ?

ECG of the Week – 15th June 2015 – Interpretation

This week's ECG is from an 82 yr old male who presented with worsening heart failure.


Click to enlarge
Rate:
  • 60 bpm
Rhythm:
  • Regularly irregular
  • Alternating Atrial (A) and Ventricular (V) pacing
Axis:
  • LAD for both A-paced & V-paced complexes
Intervals:
  • QRS - Prolonged (160-180ms)
Segments:

  • Discordant ST segment and T wave changes
  • Native ventricular complexes are Sgarbossa negative

Additional:

  • A-pacing associated with native LBBB ventricular morphology
  • V-pacing associated with RBBB morphology
    • Frontal QRS axis ~-75 degrees with transition at V6

Interpretation:

  • Alternating A & V pacing
  • Native LBBB
  • V-paced rhythm associated with RBBB morphology


Is RBBB morphology during right ventricular pacing always due to lead malposition ?

The short answer to this is no. There are cases in which an RBBB morphology can occur with appropriate right ventricular apical pacing.

In this case the patient had a chest x-ray which showed appropriate lead placement, for an example of RBBB morphology associated with lead malposition check out this case here.

Features which may assist in differentiating between lead malposition and correct placement are:
  • Frontal plane axis
  • Precordial transition point
  • Repositioning of leads V1-2

I would recommend the following freely available papers which both include a review of RBBB morphology during right ventricular pacing.
  • Erdogan O, Aksu F. Right bundle branch block pattern during right ventricular permanent pacing: Is it safe or not? Indian Pacing Electrophysiol J. 2007 Aug 1;7(3):187-91. PMID: 17684578   Full text here
  • Almehairi M, Baranchuk. Right Bundle Branch Block Morphology During Apical Right Ventricular Pacing. The Journal of Innovations in Cardiac Rhythm Management, 4 (2013), 1303–1304. Full text 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.