ECG of the Week - 26th February 2018 - Interpretation

The following ECG is from a 74yr old male who presented following an episode of 10 mins of chest pain with associated dysponea. He has a medical history of T2DM, hypertension and TCC bladder.

Click to enlarge

Rate:

• 66 bpm

Rhythm:

• Regular
• Sinus rhythm

Axis:

• Normal

Intervals:

• PR - Prolonged (~240ms)
• QRS - Normal (80ms)
• QT - 380ms (QTc Bazette 400 ms)

Additional:

• T wave inversion lead aVL
• Prominent T waves in inferior leads
• T wave in lead III is larger than QRS
• T wave lead aVF as tall as QRS
• Possibly subtle STD in lead I although baseline is a little irregular

What happened ?

The patient had a troponin rise of 0.14 [cTnI normal <=0.05]. He was admitted under the cardiology team and subsequent angiogram showed an RCA stenosis which was successfully stented.

T wave morphology and the significance of aVL in inferior ACS

When I reviewed these ECG's I was immediately concerned about inferior ischemia although the changes are subtle they are there. ST depression and T wave inversion in lead aVL. This is wholly due to the great educational work of Dr Stephen Smith in sharing both his expertise and great range of clinical ECG cases on his blog - Dr Smith's ECG Blog.
Dr Stephen Smith's ECG blog has a wide range of excellent cases that highlight how subtle ECG features of ACS can be and the need to scrutinize the ECG for these features. Check out these cases from Dr Smith:

• Abnormalities in lead aVL 
• Hyperacute T-waves

References / Further Reading

Textbook

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