ECG Review
How Many Findings?
By Ken Grauer, MD, Professor, Department of Community Health and Family Medicine, University of Florida. Dr. Grauer is the sole proprietor of KG-EKG Press, and publisher of an ECG pocket brain book.
 |
Scenario: The ECG above was obtained from a 61-year-old woman. There are a number of abnormal findings on this tracing. How many can you identify? Depending on the clinical history, which of these findings might be cause for immediate concern?
Interpretation: The mechanism of the rhythm is sinus, as determined by the presence of an upright and conducting (fixed PR interval) P wave in lead II. Slight irregularity of the rhythm and a rate in the 50s classifies it as sinus bradycardia and arrhythmia. There is 1st degree AV block (PR interval clearly exceeds 0.20 second). In addition, the QRS complex is wide in a pattern that most resembles complete right bundle branch block (RBBB), albeit there is no more than the tiniest of S waves in lead I. In addition to RBBB, the marked left axis deviation (LAD) with predominantly negative QRS in lead II qualifies this as bifascicular block (RBBB and LAHB = left anterior hemiblock). We suspect left ventricular hypertrophy (LVH). While the specificity of ECG criteria for diagnosis of ventricular enlargement is less in the presence of conduction defects, the marked amplitude (well over 12 mm) of the R wave in lead aVL in conjunction with ST-T wave changes in leads I and aVL consistent with "strain" suggest at least probable LVH. The Q wave in lead aVL is also a bit wider and deeper than usual for a "normal septal Q wave," and could reflect prior infarction. However, the findings of potential immediate concern are: 1) the constellation of sinus bradycardia and arrhythmia with 1st degree AV block and bifascicular block that may reflect significant conduction system disease and/or sick sinus syndrome, which if new and producing of symptoms, might merit consideration of a pacemaker; and 2) the upright T wave in lead V1 that is not normal in the setting of RBBB. This reflects a primary T wave change in association with RBBB, and could reflect acute ischemia. Clinical correlation is key to the interpretation of this tracing..
The ECG above was obtained from a 61-year-old woman. There are a number of abnormal findings on this tracing. How many can you identify? Depending on the clinical history, which of these findings might be cause for immediate concern?You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content