Wednesday, 30 March 2016

ECG of the Week - 28th March 2016 - Interpretation

The following ECG series is froma 58 year old male who was referred by his GP following 14 hours of central chest pain. His past medical history included hypertension, hypercholesterolemia, and smoking.


ECG at GP's
Click to enlarge
 Rate:
  • 78 bpm
Rhythm:
  • Regular
  • Sinus rhythm
Axis:
  • LAD
Intervals:
  • PR - Normal (~200ms)
  • QRS - Normal (100ms)
  • QT - 400ms
Segments:
  • ST Elevation leads III, aVF (~1mm)
    • ? Inferio Q wave ? rS wave
  • ST Depression aVL
Interpretation:
  • Delayed Inferior STEMI

ECG on arrival ED
Performed ~ 60 minutes after ECG above
Click to enlarge
 Rate:
  • 75 bpm
Rhythm:
  • Sinus Arrhythmia
Axis:
  • Normal
Intervals:
  • PR - Normal (~200ms)
  • QRS - Normal (100ms)
  • QT - 400ms (QTc Bazette 380-400 ms)
Segments:
  • Inferior ST segment elevation improved compared with previous ECG
Additional:
  • Complex #10 - fusion / PJC
Interpretation:
  • Dynamic ECG changes in a patient with ongoing chest pain
ECG performed ~60 minutes after initial ED ECG
Click to enlarge
Rate:
  • 102
Rhythm:
  • Regular
  • Nil p waves
Axis:
  • LAD
Intervals:
  • QRS - Prolonged (100ms)
Segments:
  • Discordant ST segment change
Additional:
  • Not typical LBBB / RBBB Morphology
Interpretation:
  • Accelerated Idioventricular Rhythm
What happened ?

Following discussion with cardiology team due to dynamic ECG changes and ongoing chest pain he was taken for urgent Coronary Angiogram, which showed:
  • LMCA- Irregularities
  • Prox LAD- Irregularities
  • Mid/distal LAD- 70-80%, multiple discrete lesions
  • Ostial 1st Diag- 99%, single discrete lesion, small vessel
  • Cx- Irregularities
  • Prox RCA- 90%, single discrete lesion
  • Mid RCA- 100%, unknown length stenosis, heavy thrombus burden
6 stents were inserted into the RCA extending into the PLA. The patient's stay was complicated by a lower GI bleed which settled without invasive treatment and he was discharge with out-patient cardiology follow-up on dual anti-platelet therapy (DAPT).
Post PCI ECG
Click to enlarge

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.