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- Sinus rhythm
- PR - Normal (~180ms)
- QRS - Prolonged (200ms)
- QT - 400ms (QTc Bazette 380-400 ms)
- 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.
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
- Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.