Wednesday, 28 November 2012

ECG of the Week - 26th November 2012 - Interpretation


Another two parter again this fortnight.
This ECG is from an 81 year old male.
 
 
Click to enlarge
 
Rate:
  • ~60
Rhythm:
  • Regular
  • Sinus Rhythm

Axis:
  • LAD (<-30 deg)
Intervals:
  • PR - Normal (~180-200ms)
  • QRS - Prolonged (140ms)
  • QT - 440ms (QTc Bazette ~ 430 ms)

Additional:
  • rsR' Pattern V1
  • T Inversion aVR, V1
  • Biphasic T wave V2
  • Broad Notched P wave Lead II
  • Notching of baseline following first QRS complex in leads I, II, III – likely artefact
Interpretation:
  • Bifasicular Block - RBBB + LAFB
  • P Mitrale

Some thoughts:

  • In the setting of syncope with bifasicular block with features suggestive of cardiac syncope or absence of other clear cause for syncope cardiology referral for consideration of prophylaxtic pacing is appropriate.
    • (ACC/AHA/HRS 2008 Guidelines Class IIa Level B Recommendation) 
  • The clinical context of a RBBB is important in the clinical decision making. New onset RBBB with symptoms to suggest infarction would make you think of a proximal LAD lesion, proximal to the first septal perforator branch.
  • Note that an LAD occlusion does not give a LBBB.


References / Further Reading
 
Life in the Fast Lane
 
  • Bifasicular Block here
  • Left Anterior Fasicular Block here
  • Left Posterior Fasicular Block here
Article
  • ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: Title and subTitle BreakA Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices) J Am Coll Cardiol. 2008;51(21):e1-e62 here

Textbook
  • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.