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| Click to enlarge Patient's initial ECG |
- 90 bpm
- Sinus arrhythmia
- Normal (~25 deg)
- PR - Normal (~130ms)
- QRS - Normal (100ms)
- QT - 320ms (QTc Bazette ~390 ms)
- Partial RBBB
- rSr' in lead V1
- Baseline artifact in left precordial and inferior leads
- Essentially normal ECG without concerning features
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| Click to enlarge 2nd ECG ~60 mins following 1st ECG |
- 78 bpm
- Regular
- Ventricular rhythm
- Sinus activity difficult to see given poor rhythm strip
- Possible p waves seen in ST / T junction in lead III and V3
- Inferior / subtle right axis deviation
- aVF clearly positive but lead I either isoelectric (= inferior axis ~90 deg) or slight negative (= minor RAD)
- QRS - Prolonged (120-160 ms)
- Appropriate ST segment and T wave discordant change
- Expected given ventricular origin of rhythm
- Extensive baseline artifact in leads I, II, aVR, aVL and rhythm strip
- Not typical LBBB morphology
- Clear R wave in leads V1-2
- Lack of R wave in leads I, aVL
- Nil capture or fusion beat
- Accelerated idioventricular rhythm
- Given the Inferior access and some LBBB features a concern of RVOT (Right ventricular outflow tract tachycardia) was raised although the rate is <100 bpm
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| Click to enlarge 3rd ECG ~5 mins after 2nd ECG |
- Mean ventricular rate 90 bpm
- Initial sinus rhythm with sinus arrhythmia
- Complex #13 fusion beat
- Complex #14 and #15 (partially captured) ventricular in origin with morphology similar to 2nd ECG
- Majority of the ECG is same and the patient's 1st ECG with a rhythm change in the last few complexes.
- Sinus --> Fusion --> Ventricular rhythm
- Transition captured between features seen in both 1st and 2nd ECG
- Patient noted associated palpitations
The patient was admitted under the cardiology team for investigation of episodic broad complex rhythm with associated palpitations. He had a normal transthoracic echo. negative stress test, normal coronary angiography and a caradiac MRI which showed no evidence of infiltrative disease or RV wall / outflow tract abnormality.
Following electrophysiology consultation the episodes were considered non-malignant episodes of an idioventricular rhythm with preserved chronotrophic competence. Nil further management was required and the patient is able to perform all activities without limitation.
References / Further Reading
Life in the Fast Lane
Textbook
- Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.
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