ECG of the Week - 29th October 2012 - Interpretation

This ECG is from an 83 year old male patient.
Presented with shortness of breath.

Click to enlarge

 

 

Rate:

• ~155

Rhythm:

• Regular
• ? Flutter waves - best seen in precordial leads esp. V3 rate ~300bpm

Axis:

• LAD (-66 deg)

Intervals:

• QRS - Prolonged (160-200ms)
• QT - 360ms (QTc Bazette ~ 270 ms)

Segments:

• ST Depression V2-4, II
• T Inversion V1-3, I, aVL, aVR

 
Additional:
 

• RBBB Morphology with discordant ST changes
• 3rd & 19th Complexes morpholoigcally different ? Fusion
• Nil Concordence

Interpretation:

 

• Broad Complex Tachycardia
• Differentials:
• Ventricular Tachycardia
• SVT with aberrant conduction (pre-existing or rate related)
• SVT in setting of pre-excitation
• Right Bundle Branch Block Morphology
• Left Axis Deviation

• Our diagnosis is:
• Atrial Flutter 2:1 Block with either pre-existing RBBB or rate-related RBBB
• Bifasicular block

 
Further links on differentiating broad complex tachydysrhythmias and types of broad complex tachydysrhythmias can be found below.

What happened ?

• Old notes revealed a Hx of Paroxysmal Atrial Fibrillation and a pre-existing RBBB (same morphology as this ECG)
• Pt reviewed by cardiology
• Initially Tx with adensosine with no response
• Underwent DC cardioversion
• Resultant rate controlled Atrial Fibrillation
• Tx oral amiodarone.
• ECHO
• Dilated LV
• Extensive akinese of infero-posterior and lateral walls
• Severe MR
• Mild Pulmonary Hypertension
• Hypokinetic Right Ventricle
• Mod - Severe systolic impairment.

References / Further Reading

 

Life in the Fast Lane

 

• SVT vs VT here
• Ventricular Tachycardia here
• Fasicular VT here

ECGpedia.org

• Approach to Wide Complex Tachycardia here

Textbook

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