Wednesday, 12 March 2014

ECG of the Week - 10th March 2014 - Interpretation

This ECG is from a 77 year old female who presented with dysponea and palpitations. Medical history of ischaemic heart disease. Clinical examination consistent with cardiac failure.
Check out the comments from the original case post here.



Click to enlarge
Rate:
  • Mean ventricular rate ~66 bpm
  • Atrial activity rate ~68 bpm
Rhythm:
  • Regular atrial activity
  • Sinus rhythm
    • Regular unifocal PVC's
    • Pattern - P-QRS, P-QRS, PVC
    • Full compensatory associated with PVCs
Axis:
  • Sinus complexes - LAD
  • PVCs - Normal
Intervals - Sinus Complexes:
  • PR - Prolonged (~210ms)
  • QRS - Prolonged (180ms)
  • QT - 440ms
Interval - PVCs:
  • QRS - Prolonged (160ms)
  • QT - 400ms
Segments:

  • Sinus complexes - Discordant ST segment & T wave changes
    • ST Elevation leads III, aVF, aVR, V1-4
    • ST Depression leads I, aVL, V6
    • T wave inversion leads I, II, aVL
Additional:
  • LBBB Morphology - sinus complexes
  • P waves broad (120ms) and notched lead II
    • Intra-atrial block
Interpretation:
  • Trigeminy
  • LBBB
  • 1st Degree AV Block
What happened

This patient presented with severe cardiac failure and an out-of-hospital collapse. The ECG features of LBBB and 1st degree AV block were longstanding with no acute change in the LBBB morphology. 

The patient had a normal potassium but was profoundly acidotic, ABG below :

  • pH 6.9
  • pCO90 [mmHg]
  • PO96 [mmHg]
  • HCO18 [mmol/L]
  • Lactate 11 [mmol/L]
  • Anion Gap 17 [mmol/L]


Previous ECHO, over 12 month prior, had shown the following:

  • Dilated LV with inferolateral akinesis
  • Severe LV impairment
  • Severe mitral regurgitation
  • Severely dilated left atrium
  • Severe pulmonary hypertension


Last angiogram, over 12 month prior, showed: 

  • LAD - 70% proximal stenosis
  • RCA - 30% proximal stenosis, 50% distal stenosis

Given associated extensive co-morbidites and previous unsuitability for invasive treatment management focused on symtpomatic relief and comfort measures only. 

References / Further Reading

Life in the Fast Lane

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