Friday, 16 November 2012

ECG of the Week - 19th November 2012

This ECG is from a 49 year old.
Self-presented with chest pain, initial ECG is below.

Click to enlarge


  1. I'll cover the left third first.

    Rate: ~70 bpm
    Regularity: regular
    P-waves: Inverted in I, upright in II/III.
    PRi: ~180ms, associated 1:1.
    QRSd: Narrow, ~100ms
    QTc: normal (<1/2 RR)
    P Axis: Rightward, left atrial focus or lead misplacement
    QRS Axis: Normal
    ST/T-waves: downsloping ST-segments w/ ST-depression consistent with ischemia
    Rhythm: ectopic atrial rhythm (or sinus rhythm with lead misplacement)

    Right two-thirds:

    Early coupled PVC (+aVR) initiating PMVT devolving into primary VF. Not calling TdP due to normal QTc prior to initiation. Given ST/T-wave changes and patient complaint we should consider an ischemic cause of this event.

    Dx: ectopic atrial rhythm with PVC initiating PMVT/VF due to ischemia (ACS).

    Rx: defibrillation, consider an antiarrhythmic. Confirm lead placement once arrhythmias are taken care of.

  2. my post vanished, or perhaps I did not submit it properly few days ago... anyway.... once again.

    initally I,II,III regular rythm ~ 70/min. However P wave inversion in I is against Sinus Rythm Criteria. Therefore either incorrectly placed leads (right-left arm) or less likely but possible dextrocardia. So check the leads to exclude technical error and listen to the heart :)
    P mitrale in III, but again lets check the leads! Then polymorphic looking VT, which suggests Torsade de Pointes with ventricular rate ~ 300/min. QT does not look overtly prolonged, so wldn't expect a long QTc.
    Chest pain and polymorphic VT, still ACS high on my list, especially with those ST depressions in I,II. Also low Mg?
    Hypomagnesemia/ hypokalemia? I would give 2g of Magnesium anyway. Patient by definition is unstable (as per ALS) because has chest pain, so electricity 200J.... and call Cardiology :)

    Had a patient once who was given amiodarone for TdP by Physicans. (after Mg of course:)