ECG of the Week - 29th August 2016 - Interpretation

This ECG is from a 71 yr old male who presented complaining of central chest pain. He has a history of embolic CVA a year prior and prior MI with stenting.

Click to enlarge

Rate:

• 66

Rhythm:

• Regular
• Sinus rhythm

Axis:

• Normal

Intervals:

• PR - Normal (~180ms)
• QRS - Prolonged (200ms)
• QT - 400ms (QTc Bazette 380-400 ms)

Segments / Additional:

• LBBB
• Discordant ST segment change with appropriate magnitude
• See the Life in the Fast Lane post and the Smith paper below for an explanation of 'excessive' discordance
• Lead V3 looks concerning for ACS
• The initial R wave is a little large than usually seen in LBB but may reflect poor lead placement
• Given the principally negative voltage of the QRS I would have expected more ST elevation rather than a neutral / subtley depressed ST segment.
• There isn't enough ST elevation to make this lead Sgarbossa positive but I'd be closely looking at serial ECG's for change

What happened ?

The patient was admitted under cardiology and coronary angiography showed:

• Distal LMCA: 60-70% stenosis
• Proximal LAD: 60-70% stenosis
• Ostial 1st diagonal: 70% stenosis
• Proximal Cx: 80% stenosis
• Mid-RCA: 90% stenosis

The patient then underwent CABG for treatment of his multi-vessel disease.

Sgarbossa Criteria

I'm not going to reinvent the wheel here regarding Sgarbossa and the modified Sgarbossa criteria as there are several great reviews listed below:

• Smith's Modified Sgarbossa Criteria AEM Paper
• Sgarbossa Criteria - Life in the Fast Lane ECG Library
• R.E.B.E.L. ECG of the Week: LBBB and STEMI - Sgarbossa & Modified Sgarbossa

References / Further Reading

Textbook

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