Wednesday, 25 March 2015

ECG of the Week - 23rd March 2015 - Interpretation

This ECG is from a 35 yr old male who presented to the Emergency Department following an episode of exertional syncope. He has 1 previous episode of syncope several years prior without investigation. Otherwise he is fit & well with no relevant family history.
Check out the comments on our original post here.



Click to enlarge
Rate:
  • 78 bpm
Rhythm:
  • Regular
  • Sinus rhythm
Axis:
  • Normal
Intervals:
  • PR - Normal (~180ms)
  • QRS - Normal (100ms)
  • QT - 360ms (QTc Bazette 410 ms)
Segments:
  • Concave ST elevation leads V2-4
  • Nil ST depression
Additional:
  • Voltage criteria for LVH
    • R wave V5 + S wave V1 ~35mm
    • R wave aVF >20mm
  • Narrow deep Q waves leads II, III, aVF, V4-6
  • Partial RBBB pattern - rSr' in lead V1
Interpretation:
  • Given the history of exertional syncope plus LVH with infero-lateral deep Q waves the major concern would be hypertrophic cardiomyopathy.

What happened ?

The ECG changes were appreciated and the patient had a cardiology review and urgent echo. His echo was entirely normal and he was discharged with out-patient cardiology follow-up.

For a bit more on echo findings in HCM and new echo modalities check out the following:

  • Williams LK, Frenneaux MP, Steeds RP. Echocardiography in hypertrophic cardiomyopathy diagnosis, prognosis, and role in management. Eur J Echocardiogr. 2009 Dec;10(8):iii9-14 PMID: 19889657 Full text here
  • Afonso LC, Bernal J, Bax JJ, Abraham TP. Echocardiography in Hypertrophic Cardiomyopathy The Role of Conventional and Emerging Technologies. J Am Coll Cardiol Img. 2008;1(6):787-800. Full text here.
  • Losi MA, Nistri S, Galderisi M, Betocchi S, Cecchi F, Olivotto I, Agricola E, Ballo P, Buralli S, D'Andrea A, D'Errico A, Mele D, Sciomer S, Mondillo S; Working Group of Echocardiography of the Italian Society of Cardiology. Echocardiography in patients with hypertrophic cardiomyopathy: usefulness of old and new techniques in the diagnosis and pathophysiological assessment. Cardiovasc Ultrasound. 2010 Mar 17;8:7. Full text here
I was wondering on our readers thoughts on diagnostic criteria for HCM and the reliability /negative predictive value of a normal resting echo in these cases. Do patients need to go on for dynamic testing (stress echo) and/or cardiac MRI ?

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.