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
Click to enlarge

 

Pain-free ECG
Click to enlarge



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 – 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.