Wednesday, 3 August 2016

ECG of the Week - 1st August 2016 - Interpretation

The following ECG is from a 55 yr old male who presented with chest pain. He is a smoker with a history of controlled hypertension.




Click to enlarge


Rate:
  • 66 bpm
Rhythm:
  • Sinus arrhythmia
Axis:
  • Right axis deviation
Intervals:
  • PR - Normal (~180ms)
  • QRS - Normal (110ms)
  • QT - 400ms (QTc Bazette 420 ms)
Segments:

  • ST elevation leads I (<1mm), aVL (0.5-1mm), V1 (<1mm), V2-3 (1mm)
  • ST depression lead III

Additional:

  • P wave prolonged 110ms and notched in lead II consistent with left atrial abnormality
  • Poor R wave progression
  • Concordant T wave inversion leads III & aVF
  • R wave aVL ~11mm - LVH voltage criteria

Interpretation:

  • Sinister features for ACS include concordant T wave inversion in inferior leads and concordant ST elevation in high lateral leads (I, aVL)
  • ST changes in the right precordial leads (V1-3) may be explained by LVH

What happened ?

Initial troponin was elevated at 5.69 (cTnI [<0.05 ug/L]). The patient was admitted under cardiology and had an angiogram which showed:

  • LMCA: Normal
  • LAD: 30-40% stenosis mid and distal
  • Cx: Irregularities
  • RCA: 30-40% stenosis mid vessel
  • 2nd OM: 100% occlusion with RCA collaterals - DES inserted

Post angio echo showed:

  • EF 52%
  • Hypokinesis of lateral wall of left ventricle
  • Moderate concentric left ventricular hypertrophy

The patient was discharged on dual anti-platelet therapy (DAPT), beta-blocker, statin and ACE. 

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.