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This post is an answer to the ECG Case 228

• Rate: Mean ventricular rate ~78 bpm

• Rhythm:
  • Irregular
  • Atrial flutter with variable conduction
  • Premature ventricular complexes
    • Complexes #4, 6, 13

• Axis: Normal 

• Intervals:
  • QRS – Normal (80-100ms)
  • QT – 360ms

• Segments:
  • ST elevation inferior leads
    • Measurement difficult due to flutter waves
  • ST depression leads I & V1-6 

What happened next?

In addition to the palpitations the patient also complained of central chest pain of similar duration. He had no significant past medical history, was not known to have atrial flutter and was on no regular medication.

Addition serial ECG’s performed on arrival were similar to the ECG above with the inferior ST changes remaining challenging to quantify due to flutter waves and ectopic beats. No posterior leads were performed.The cardiology team were involved urgently given acute nature of the presentation.

The patient underwent urgent PCI, which showed:

• LMCA: Normal
• LAD: Mild-mod diffuse irregularities
• LCx: 100% occlusion after OM1 which was stented
• RCA: Dominant with 30% proximal stenosis
• LV: Normal

Following the PCI the patient remained in atrial flutter for which he underwent successful DC cardioversion following transoesophageal echo.

READ MORE:

• Atrial Flutter: ECG Interpretation [With Examples]
• ECG Interpretation: All you need to know