ECG of the Week - 20th April 2015 - Interpretation

This week's ECG is form a 73 yr old male who presented to the Emergency Department complaining of 10+ hours of chest pain, sore throat, cough and dysponea. He has an AICD in situ and known cardiomyopathy (EF 25%). Vital signs were within normal limits. 
Check out the comments on our original post here.

Click to enlarge

Rate:

• Mean ventricular rate 96 bpm

Rhythm:

• Sinus complexes each followed by unifocal ventricular ectopics 
• Bigeminy

Axis:

• Sinus complexes
• Normal
• Ventricular ectopics
• RAD

Intervals:

• Sinus complexes
• PR - Normal (~160ms)
• QRS - Normal (80ms)
• QT - 400ms (QTc Bazette 380-400 ms)
• Ventricular complexes
• QRS - Prolonged (160-180ms)

Segments:

• Sinus Complexes
• ST Elevation lead aVR (2mm)
• ST Depression leads V2-6
• Down sloping baseline makes ST segments in the inferior leads difficult to assess
• Ventricular complexes
• Appropriate discordant 

Interpretation:

• Bigeminy
• Diffuse ST depression with ST elevation in lead aVR

The Bigeminy Challenge - 'Seeing the Wood for the Trees'

Multiple PVC's can prove a distraction particularly when trying to assess ST segment change as the PVC's tend to draw the eye. I've used Paint to remove the PVC's from our ECG above and the ST changes in the native complexes are clearly more apparent. You can do this with hard copy ECG's by using bits of paper to cover the PVC's.

PVC's Removed
Click to enlarge

What happened ?

The patient remained in bigeminy and the ST segment changes were seen on older ECG's. Prior angiogram showed diffuse multi-vessel disease. The patient troponin was significantly elevated and a repeat angiogram was performed during which the the left circumflex was stented.

References / Further Reading

Life in the Fast Lane

• Bigeminy
• ST Elevation in lead aVR 

Textbook

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