ECG of the Week - 26th November 2012 - Interpretation

Another two parter again this fortnight.
This ECG is from an 81 year old male.

 

 

Click to enlarge

 

Rate:

• ~60

Rhythm:

• Regular
• Sinus Rhythm

Axis:

• LAD (<-30 deg)

Intervals:

• PR - Normal (~180-200ms)
• QRS - Prolonged (140ms)
• QT - 440ms (QTc Bazette ~ 430 ms)

Additional:

• rsR' Pattern V1
• T Inversion aVR, V1
• Biphasic T wave V2
• Broad Notched P wave Lead II
• Notching of baseline following first QRS complex in leads I, II, III – likely artefact

Interpretation:

• Bifasicular Block - RBBB + LAFB
• P Mitrale

Some thoughts:

• In the setting of syncope with bifasicular block with features suggestive of cardiac syncope or absence of other clear cause for syncope cardiology referral for consideration of prophylaxtic pacing is appropriate.
• (ACC/AHA/HRS 2008 Guidelines Class IIa Level B Recommendation) 
• The clinical context of a RBBB is important in the clinical decision making. New onset RBBB with symptoms to suggest infarction would make you think of a proximal LAD lesion, proximal to the first septal perforator branch.
• Note that an LAD occlusion does not give a LBBB.

References / Further Reading

 

Life in the Fast Lane

 

• Bifasicular Block here
• Left Anterior Fasicular Block here
• Left Posterior Fasicular Block here

Article

• ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: Title and subTitle BreakA Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices) J Am Coll Cardiol. 2008;51(21):e1-e62 here

Textbook

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