Blog

This post is an answer to the ECG Case 226

• Rate:
  • Mean ventricular rate ~66 bpm
  • Atrial activity rate ~68 bpm

• Rhythm:
  • Regular atrial activity
  • Sinus rhythm
    • Regular unifocal PVC’s
    • Pattern – P-QRS, P-QRS, PVC
    • Full compensatory associated with PVCs

• Axis:
  • Sinus complexes – LAD
  • PVCs – Normal

• Intervals – Sinus Complexes:
  • PR – Prolonged (~210ms)
  • QRS – Prolonged (180ms)
  • QT – 440ms
• Interval – PVCs:
  • QRS – Prolonged (160ms)
  • QT – 400ms

• Segments:
  • Sinus complexes – Discordant ST segment & T wave changes
    • ST Elevation leads in III, aVF, aVR, V1-4
    • ST Depression in leads I, aVL, V6
    • T wave inversion in leads I, II, aVL

• Additional:
  • LBBB Morphology – sinus complexes
  • P waves broad (120ms) and notched in lead II
    • Intra-atrial block

Interpretation

• PVCs in Trigeminy
• LBBB
• 1st Degree AV Block

What happened next ?

This patient presented with severe cardiac failure and an out-of-hospital collapse. The ECG features of LBBB and 1st degree AV block were longstanding with no acute change in the LBBB morphology.
The patient had a normal potassium but was profoundly acidotic, ABG below :

• pH 6.9
• pCO2 90 [mmHg]
• PO2 96 [mmHg]
• HCO3 18 [mmol/L]
• Lactate 11 [mmol/L]
• Anion Gap 17 [mmol/L]

Previous ECHO, over 12 month prior, had shown the following:

• Dilated LV with inferolateral akinesis
• Severe LV impairment
• Severe mitral regurgitation
• Severely dilated left atrium
• Severe pulmonary hypertension

Last angiogram, over 12 month prior, showed: 

• LAD – 70% proximal stenosis
• RCA – 30% proximal stenosis, 50% distal stenosis

Given associated extensive comorbidities and previous unsuitability for invasive treatment management focused on symptomatic relief and comfort measures only.

READ MORE:

• ECG Interpretation: All you need to know
• Conduction Blocks at the AV Node (AV Blocks) [With Examples]