Saturday, 26 December 2015

ECG of the Week - 21st December 2015 - Interpretation

This ECG is from a 40 yr old male who presented with hypertension.



Click to enlarge
 Rate:

  • 72
Rhythm:
  • Regular
  • Sinus rhythm
Axis:
  • Normal 
Intervals:
  • PR - Normal (~180ms)
  • QRS - Normal (80ms)
  • QT - 320ms (QTc Bazette 380-400 ms)
Segments:
  • ST Elevation leads I (0.5mm) aVL (0.5mm) V1 (2mm) V2 (3mm) V3 (2mm)
    • Concave morphology
  • ST Depression III, aVF, V5-6
Additional:
  • T wave inversion leads III, V4-6
  • Broad P wave in inferior leads with biphasic P wave in V1
    • Left atrial abnormality (LAA)
  • Voltage criteria LVH
    • aVR ~14mm
    • R wave V5 + S wave V1 ~35-36mm
    • LV 'Strain' features - lateral ST depression and T wave inversion

Interpretation:
  • LVH with secondary ST / T wave changes
  • V3 suspicious for ACS given relative height of ST elevation in relation to R-S magnitude
    • Seen links below
What happened ?

The patient had attended hospital ~2 yrs prior with chest pain and a similar ECG. At that time the patient was taken for urgent PCI which showed no artery disease and normal LV function. Biomarkers were negative with an echo showing mild-moderate LVH.

This presentation's ECG showed no new changes, when compared with previous, and serial biomarkers were negative.

There are a few nice reviews on LVH and ACS look at decision rules to help distinguish LVH from LVH + acute AMI that I'd recommend:
Also a number of cases from Dr Smith involving LVH:
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.