Wednesday, 7 November 2018

ECG of the Week - 5th November 2018 - Interpretation

This ECG is from a 70 yr old male with a history of hypertension who presented with epigastric pain.

 
Click to enlarge

Rate:
 
  • Mean ventricular rate 66 bpm
Rhythm:
 
  • Sinus rhythm
  • Unifocal PVC's x 2 
Axis:
  • Normal (-25 deg)
Intervals:
  • PR - Normal (~190ms)
  • QRS - Prolonged (120-125 ms)
Additional:
  • LBBB Morphology
    • Without callipers the QRS looks <120ms 125ms="" at="" but="" calliper="" font="" get="" i="" it="" measurement="" on="">
    • Sgarbossa Negative
  • High voltage
    • Would met LVH voltage criteria in isolation - I can't find consistent criteria for LBBB with LVH - obviously the ECG remains poorly sensitive for chamber hypertrophy regardless
  • Discordant ST segment / T wave changes
    • Likely secondary to abnormal repolarisation
 
Interpretation:
  • Abnormal repolarisation secondary to LBBB +/- LVH
  • ST / T changes likely secondary to above - no consistent with concurrent ACS
What happened ?

There was concern about the patient's ECG, nil prior for comparison or prior cardiac investigations, and whether the pain could be of cardiac origin.
Serial biomarkers were negative and the patient discharged themselves against medical advice before an echo could be performed.

ST Assessment in LV Hypertrophy
 There is a great review by Dr Smith on the challenges of ST segment assessment in the setting of LVH that I'd recommend here:

http://hqmeded-ecg.blogspot.com/2015/12/lvh-with-anterior-st-elevation-when-is.html

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