Wednesday, 31 August 2016

ECG of the Week - 29th August 2016 - Interpretation

This ECG is from a 71 yr old male who presented complaining of central chest pain. He has a history of embolic CVA a year prior and prior MI with stenting.



Click to enlarge
Rate:
  • 66
Rhythm:
  • Regular
  • Sinus rhythm
Axis:
  • Normal
Intervals:
  • PR - Normal (~180ms)
  • QRS - Prolonged (200ms)
  • QT - 400ms (QTc Bazette 380-400 ms)
Segments / Additional:

  • LBBB
  • Discordant ST segment change with appropriate magnitude
    • See the Life in the Fast Lane post and the Smith paper below for an explanation of 'excessive' discordance
  • Lead V3 looks concerning for ACS
    • The initial R wave is a little large than usually seen in LBB but may reflect poor lead placement
    • Given the principally negative voltage of the QRS I would have expected more ST elevation rather than a neutral / subtley depressed ST segment.
    • There isn't enough ST elevation to make this lead Sgarbossa positive but I'd be closely looking at serial ECG's for change

What happened ?

The patient was admitted under cardiology and coronary angiography showed:

  • Distal LMCA: 60-70% stenosis
  • Proximal LAD: 60-70% stenosis
  • Ostial 1st diagonal: 70% stenosis
  • Proximal Cx: 80% stenosis
  • Mid-RCA: 90% stenosis

The patient then underwent CABG for treatment of his multi-vessel disease.

Sgarbossa Criteria

I'm not going to reinvent the wheel here regarding Sgarbossa and the modified Sgarbossa criteria as there are several great reviews listed below:


References / Further Reading

Textbook

  • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.