ECG Review
What are the 5 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.
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Figure: 12-lead ECG and lead II rhythm strip obtained from a 67-year-old man with new-onset shortness of breath. |
Clinical Scenario:
The 12-lead ECG and lead II rhythm strip in the Figure were obtained from a 67-year old man who presented with new-onset shortness of breath. No chest pain. How would you interpret his ECG if told that a previous tracing was "normal"? Can you identify 5 ECG findings that might impact on your diagnosis?
Interpretation/Answer:
Five important ECG findings that we identify on this tracing are:
1. Atrial fibrillation (A Fib) with a rapid ventricular response. This is presumably of new-onset given the patient's acute dyspnea.
2. IRBBB (incomplete right bundle branch block) with a tall positive deflection in lead V1. The typical morphology of RBBB is seen (rsR' in lead V1, and terminal S waves in lateral leads I and V6). However, since the QRS complex is not widened, this is an incomplete RBBB. In the context of new-onset rapid A Fib, acute dyspnea, and the surprisingly tall positive (R') component of the QRS complex in lead V1the possibility of RVH (right ventricular hypertrophy) and/or pulmonary embolism should be considered.
3. Diffuse ST segment depression (in precordial leads V2 through V6). This could be due to ischemia, "strain," digitalis effect (if the patient was on this drug), hypokalemia/hypomagnesemia, rapid heart rateand/or any combination of the above.
4. Small, but definitely present inferior q waves. We are told that this patient's previous ECG was normal, so these q waves could be new and indicative of inferior infarction of uncertain age.
5. Distortion of the baseline in the inferior leads. Given new-onset of this patient's symptoms and tachyarrhythmia that occur in the setting of diffuse precordial ST segment depression and possibly new inferior q waves, special attention should be directed at assessing the ST segment in the inferior leads. Baseline distortion from either artifact or "fib waves" makes it impossible to tell if the subtle ST elevation and T wave inversion seen in some of the QRS complexes in leads III and aVF is real. Serum troponins became positive in this patient, confirming that acute infarction did occur.
12-lead ECG and lead II rhythm strip obtained from a 67-year-old man with new-onset shortness of breath.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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