ECG of the Week - 1st August 2016 - Interpretation

The following ECG is from a 55 yr old male who presented with chest pain. He is a smoker with a history of controlled hypertension.

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Rate:

• 66 bpm

Rhythm:

• Sinus arrhythmia

Axis:

• Right axis deviation

Intervals:

• PR - Normal (~180ms)
• QRS - Normal (110ms)
• QT - 400ms (QTc Bazette 420 ms)

Segments:

• ST elevation leads I (<1mm), aVL (0.5-1mm), V1 (<1mm), V2-3 (1mm)
• ST depression lead III

Additional:

• P wave prolonged 110ms and notched in lead II consistent with left atrial abnormality
• Poor R wave progression
• Concordant T wave inversion leads III & aVF
• R wave aVL ~11mm - LVH voltage criteria

Interpretation:

• Sinister features for ACS include concordant T wave inversion in inferior leads and concordant ST elevation in high lateral leads (I, aVL)
• ST changes in the right precordial leads (V1-3) may be explained by LVH

What happened ?

Initial troponin was elevated at 5.69 (cTnI [<0.05 ug/L]). The patient was admitted under cardiology and had an angiogram which showed:

• LMCA: Normal
• LAD: 30-40% stenosis mid and distal
• Cx: Irregularities
• RCA: 30-40% stenosis mid vessel
• 2nd OM: 100% occlusion with RCA collaterals - DES inserted

Post angio echo showed:

• EF 52%
• Hypokinesis of lateral wall of left ventricle
• Moderate concentric left ventricular hypertrophy

The patient was discharged on dual anti-platelet therapy (DAPT), beta-blocker, statin and ACE. 

References / Further Reading

Life in the Fast Lane

• Poor R wave progession
• Left ventricular hypertrophy
• Left atrial abnormality

Textbook

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