ECG of the Week - 23rd July 2018 - Interpretation

The following ECG is from a 71yr old male who presented with several episodes of ischaemic sounding chest pain on a background of known ischaemic cardiac disease.

Click to enlarge

Rate:

• Mean rate 66 bpm

Rhythm:

• Sinus rhythm
• Unifocal PVCs

Axis:

• Normal

Intervals:

• PR - Normal (~200ms)
• QRS - Prolonged (120-130 ms)
• QT - 410ms (QTc Bazette 470 ms)

Additional:

• QRS fragmentation 
• Best seen leads V2-3
• Lead V2 rsr's'r''s'' pattern
• Lead V3 rsr's' pattern
• T wave inversion leads V4-5
• ST elevation leads aVR and aVL (< 1mm)<1mm font="">
• ST depression leads II, III, aVF

Interpretation:

• ST and T wave changes
• Likely ACS given history 
• Needs serial ECGs and comparison with prior ECGs
• QRS Fragmentation
• Caused by abnormal ventricular repolarisation
• Due to myocardial scarring, fibrosis or ischaemia

QRS Fragmentation

The two following papers are a great overview of QRS fragmentation including diagnostic morphologies and clinical relevance in terms of associations and effects on morbidity and mortality.

• Jain R, Singh R, Yamini S, Das MK. Fragmented ECG as a Risk Marker in Cardiovascular Diseases. Current Cardiology Reviews. 2014;10(3):277-286. doi:10.2174/1573403X10666140514103451.
• Mittal SR. Fragmented QRS: A simple electrocardiographic prognostic marker in cardiovascular disease. J Clin Prev Cardiol [serial online] 2016 [cited 2018 Jun 30];5:94-8. Available from: http://www.jcpconline.org/text.asp?2016/5/3/94/191100

References / Further Reading

Life in the Fast Lane

• PVC's

Textbook

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