Wednesday, 19 September 2012

ECG of the Week - 17th September 2012 - Interpretation

I've got no information on this weeks ECG but let's see what we can make of it.





Click to enlarge


Rate:
  • 78
Rhythm:
  • Regular
  • Sinus Rhythm
Axis:
  • Right Axis Deviation (+100 deg)
Intervals:
  • PR - Prolonged (~320ms)
  • QRS - Broad (120ms) 
  • Note as Christopher has pointed out his comment there is variability in QRS width across the leads
  • QT - 380ms (QTc Bazette ~ 420 ms)
Segments:
  • ST Elevation V2-6, I, II, aVF

Additional:
  • Tall p waves lead II (~4mm)
  • Prolonged p waves lead II (120ms)
  • Notched p wave V1 (measurements difficult on image & paper copy due to photocopying - positive deflection >1mm < 2mm, negative deflection ~1mm, duration of negative deflection ~80ms)
  • Some features suggestive of LVH given RBBB pattern (Prominent R waves lateral precordial leads, R wave V5 ~29mm)
Interpretation:
  • 1st Degree AV Block
  • RBBB - using longest QRS duration (Partial RBBB using shortest) 
  • Note RAD possible bifasicular block - LPFB + RBBB 
  • Other causes for RAD also likely e.g pulmonary disease
  • Right Atrial Enlargement
  • Features of Left Atrial Enlargement - ? Biatrial Enlargement
  • Concave ST Elevation - ? Acute ? Chronic ? Dynamic 
  • ? LV Diastolic Overload - Positive T wave and ST elevation in high voltage left Precordial Leads

I'm not sure about this one, there are lots of interesting features. 
I've gone back to my papercopy of the ECG to try and source some clinical information but have come up empty handed. This is an ECG that I think really needs some correlation with the clinical picture, and ideally old ECGs. The differentials for this ECG pattern are broad and include chronic pulmonary disease, valvular disease (single or mixed), the ST changes could be acute or chronic. 
I'd like to thank people for their comments on this one and would like to encourage any further comments as I think this is one of the most interesting ECGs we've had a look at on the blog. 

References / Further Reading

Life in the Fast Lane

Articles

  • Hancock EW et al. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part V: electrocardiogram changes associated with cardiac chamber hypertrophy. Circulation. 2009 Mar 17;119(10):e251-61. Full text here.
Textbook
  • Surawicz B, Knilans TK. Chou's Electrocardiography in Clinical Practice. 6th Edition. Saunders Elsevier 2008.
  • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.