ECG of the Week: ECG of the Week - 26th August 2013

This ECG is from an 85yr old female who presented complaining of worsening dysponea and atypical chest pain. She has known atrial fibrillation and COPD.
At the time of clinical review we luckily had access to her old ECG's and a recent echo.
I plan to include her echo results with the interpretation post although the ECG might give some clues as to the findings.
Check out the original post and comments here.

Rate:

Mean ventricular rate ~96 bpm
Atrial rate ~240 bpm

Best visualised in lead V1

Rhythm:

Irregular ventricular conduction

Variable 2:1 & 3:1 conduction
R - R interval either ~2x or ~3x P-P interval

Axis:

Normal (35 deg)

Intervals:

QRS - Prolonged (~120ms)
QT - 350ms

Segments:

ST depression leads II, aVF, V1-4

Discordant to QRS vector

Nil ST elevation

Additional:

RBBB Morphology

Significant R' wave V1 ~34mm

T wave inversion leads III, aVR, V1-4

Atrial activity

Best visualised lead V1
Morphology is same for all complexes
Isoelectric line is flat
Unable to visualise in inferior leads

Interpretation:

Atrial tachycardia with variable 2:1 / 3:1 block
RBBB
Features suggestive of RVH

'Secondary ST / T wave changes right precordial leads a.k.a 'strain pattern'
Prominent R' wave V1
Note presence of RBBB complicates the interpretation of ? RVH

Many thanks to Ryan Tee who t has kindly provided a ladder diagram to illustrate the conduction problem seen in this ECG.

Click to enlarge
Image developed by Ryan Tee

In this case we were lucky to have access to the patient's old notes which revealed the ECG features were old. Her latest echo showed:

Moderate /Severe Calcific Mitral Stenosis
Severe Pulmonary Hypertension
Moderate / Severe Right Ventricular Dysfunction
Moderate Aortic Stenosis
Severe Left Atrial Dilation
Mild Right Atrial Dilation

She was admitted under the medical team for symptomatic treatment of multifactorial dysponea, combination cardiac failure and underlying pulmonary disease exacerbation.

Right Ventricular Hypertrophy on the ECG

There are multiple criteria which may suggest right ventricular hypertrophy (RVH) on the ECG, although it should be noted the ECG has low sensitivity in diagnosing RVH.
The table below is taken from Part V of the freely available AHA series of 'Recommendations for the Standardisation and Interpretation of the Electrocardiogram'(1).

Click to enlarge
RVH Diagnostic Criteria
From Ref. 1

Also please check out the further reading section for some other relevant blog posts from Life in the Fast Lane and Dr Ken Grauer.

References / Further Reading

Articles

Hancock EW, Deal BJ, Mirvis DM, Okin P, Kligfield P, Gettes LS, Bailey JJ, Childers R, Gorgels A, Josephson M, Kors JA, Macfarlane P, Mason JW, Pahlm O,Rautaharju PM, Surawicz B, van Herpen G, Wagner GS, Wellens H; American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; American College of Cardiology Foundation; Heart Rhythm Society. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part V: electrocardiogram changes associated with cardiac chamber hypertrophy: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society. Endorsed by the International Society for Computerized Electrocardiology. 2009 Mar 17;53(11):992-1002. PMID: 19281932 Full text here

Life in the Fast Lane