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This post is an answer to the ECG Case 212

• Rate: Mean ventricular rate 78 bpm

• Rhythm:
  • Complex rhythm
  • Alternating broad & narrow QRS complexes
  • Complexes #4,6,8,10
    • Sinus
    • Narrow Complex ~70ms
  • Complexes #1,3,5,7,9,11,13
    • Premature ventricular complexes (PVC)
    • Broad complexes (~140ms)
  • Complex #2
    • Preceded by abnormal p wave
    • PR interval very short (~70ms)
    • Premature junctional complex (PJC)

• Axis:
  • Sinus complexes – Inferior (~90 deg)
  • Ventricular complexes – LAD (-65 deg)

• Intervals:
  • Sinus complexes (#4,6,8,10)
    • PR – Normal (~125 ms)
    • QRS – Normal (70-80 ms)
    • QT – 480 ms
  • Ventricular  complexes (#4,6,8,10)
    • QRS – Broad (140 ms)
    • QT – 360 ms
  • Complex # 2
    • PR – Short (~70ms)
    • QRS – Normal (70-80 ms)
    • QT – 380 ms

• Segments:
  • ST Elevation – Sinus Complexes
    • Leads V1 (0.5mm) V2 (2.5mm) V3 (6mm) V4 (3mm)
  • ST Depression – Sinus Complexes
    • Leads II, III
  • Note ST elevation evident in PVC’s in leads aVL,V2, V3

• Additional:
  • Variable morphology ventricular complexes
    • #7 & #9 Notching QRS
  • Regular relationship between narrow complex and broad complex
    • R-R interval 500ms
  • Partial RBBB morphology in narrow QRS complexes

Interpretation

Acute Anterior STEMI with regular PVC’s and a single PJC.

Clinical Outcome

The ST segment changes were immediately recognised and the patient was transferred for urgent angiogram and PCI. His angiogram showed:

• LM – no stenosis
• LAD – occluded mid – PCI
• Cx – no stenosis
• RCA – dominant no stenosis
• Left ventriculogram – Ejection fraction 55%

READ MORE

• ECG Interpretation: All you need to know
• Know the Differential for ST Segment Elevation: It’s More Than Just ACS