ECG Review-An ECG Clue to a Valvular Lesion
By Ken Grauer, MD
Clinical Scenario: The ECG in the figure was ob-tained from an 80-year-old woman who presented with "fatigue." What valvular lesion should be carefully listened for in view of the findings seen in this tracing?
Interpretation: The rhythm is irregularly irregular, and atrial activity is absent. This defines the rhythm as atrial fibrillation—in this case with a controlled ventricular response. The QRS and QT intervals are normal. The mean QRS axis is +80°. There is no evidence of left ventricular hypertrophy (LVH). There are minimal, nonspecific ST-T wave abnormalities present that do not appear to be acute.
Other than the rhythm, the most remarkable finding on this tracing is the presence of a tall (and clearly predominant) R wave in lead V1. This abnormal finding that should always suggest consideration of five possible diagnoses:
1. Right bundle branch block (RBBB)
2. Wolff-Parkinson-White (WPW) syndrome
3. Posterior infarction
4. Right ventricular hypertrophy (RVH)
5. Normal variant
In this particular case, the first two entities in the above differential list can be excluded because the QRS complex is narrow. This ECG is clearly not a normal variant. Posterior infarction almost always occurs in association with evidence of inferior infarction (since the right coronary artery most often provides the blood supply to both of these areas of the heart). There is no indication of inferior infarction in this tracing. Therefore, by the process of elimination, a diagnosis of RVH should be strongly suspected as the cause for the tall R wave in lead V1 of this ECG. The finding of a nearly vertical QRS axis and persistent S waves in lateral precordial leads is consistent with this diagnosis.
The valvular lesion that should be suspected with the ECG finding of atrial fibrillation and RVH is mitral stenosis.
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