Name that ECG: 66 year old female

Welcome to another installment of Name that ECG! Remember, this is a cold read and your job is to interpret the ECG to its fullest.

66 year old female, resolved chest pain.

Name that ECG: 66 year old female

 

Rhythm:

  • Rate?
  • Regularity?
  • P-waves?
  • PR interval? Associated?
  • QRS width?

Bonus points:

  • Axis?
  • QTc?
  • ST/T-wave changes?

What are your differentials?

Posts which include any permutation of the phrase "treat the patient not the monitor" will be deleted and their author beaten with a LifePak 5.

7 Comments

  • Robert says:

    Interpretation: Sinus Brady @ 50-60 (based on upright P waves in I, II, III, avf and negative p wave in avr and hr < 60 w/ regular rhythm), Left Axis Deviation, LAFB(LAD, qr in I/AVL, rS in II, III, Avf), Biphasic T waves in V2, V3, V4 highly suggestive of Wellens Syndrome. Inverted T wave in AVL.
    Cheers!

  • Todd says:

    Wellen's Syndrome with some left axis deviation?

  • alex says:

     
    •Rate?
    About 60
     
    •Regularity?
    Regular
     
    •P-waves?
    Yes
     
    •PR interval? Associated?
    Borderline for 1st degree AVB. 1:1 association
     
    •QRS width?
    Normal at 0.08s
     
    •Axis?
    Left (positive QRS in I, negative QRS is aVF)
     
    •QTc?
    Less than half the RR interval so probably ok
     
    •ST/T-wave changes?
    Wellens waves in V2-V5
    TWI in I and aVL
     
    Which all points to partial LAD occlusion but isn't enough to activate a cath lab?

  • RyanTee says:

    Rate is about 60 bpm, regular rhythm P waves are these, PRI is good, QRS is wide with LBBB, LAD is seen..QTc is normal, Biphasic T waves seen with negative terminal – first stage of Wellens syndrome…urgent but not immediate cath…R waves are there meaning the artery is not yet infarcted…there is spontaneous reperfusion..
     

  • Ben W says:

    I definitely say it’s textbook wellen’s syndrome. Inversion in AvL and hyper acute-ish looking T waves inferiorly kinda makes me think Type III wraparound LAD occlusion due to possible inferior injury with the more obvious anterior injury. Happy holidays kids!

  • @Ryan Tee – I'm not seeing any evidence of left bundle-branch block (LBBB).  In fact, if LBBB was actually present, then it would probably mask the ST-T changes of "Wellens' warning".  The duration of the QRS interval is normally narrow at 0.08s and there are triphasic "qRs" complexes in both lead I and V6. 

  • Andrew Przepioski says:

     
    Rhythm: Sinus bradycardia
     
    Rate? 56
    Regularity? Yes.
    P-waves? Yes.
    PR interval? Associated? 0.16s. Yes.
    QRS width? 0.08s.
    Bonus points:
     
    Axis? QRS -30 degree. Z +40.
    QTc? 425 ms.
    ST/T-wave changes? Biphasic T-waves V1-V5. Retrograde in aVL.
    What are your differentials? LAD occulsion. I have nothing else to add to my DDx.
     
    =====================================================
     
    56, sinus bradycardia, LAFB, LAE, anteroseptal ischemia.
     
    Rate: 56
     
    Rhythm: Regular, p-waves present, P:QRS 1:1, PRi about 0.16s, QRS narrow 0.08s. Sinus bradycardia.
     
    Axis: QRS – I +, avF -, II -, -30 degree, LAD, LAFB (qR in I, rS in III too).
    Z V4 +40m, V1-V3 looks like the leads were placed 1 ICS too high (V3 r-wave >3 mm).
     
    Enlargement/Hypertrophy: Left atrial enlargement (2nd 1/2 of P-wave in V1 >0.04s, 1mm deep)
     
    ST/T, Q: insignificant q-waves in I and aVL. Significant Q in II and aVF. III has a small r-wave. No significant STE, but V1-V5 has retrograde T-waves. V2-V3, are those Wellen's T-waves? aVL also has a retrograde T-wave.
     
    QT 440 ms.
    QTc 425 ms.
     
    I'd be concerned about LAD occulusion cause of the T-waves in the anteroseptal leads.

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EMS 12-Lead

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation
Comments
David Baumrind
All that wiggles isn’t Wellens’
@Gary, by all means, nitpick all you like. I agree with your assessment, and the post has been modified. Thank you for the feedback!
2014-08-30 17:28:16
Gary Huntress
All that wiggles isn’t Wellens’
Not to nitpick but is this really a "slightly leftward axis"? I and AVF are both positive. I put it at about +20 degrees, not leftward.
2014-08-30 11:49:35
Handsome Robb
87 YOM COMPLAINING OF CHEST DISCOMFORT AND DYSPNEA
CHF. 12-lead shows a sinus Tachycardia in the 120s with PACs, besides the anterior leads there's diffuse ST depression, the STE in the anterior leads can be explained by the LBBB, axis is good as well. I wish they posted the EtCO2 waveform so we could see but I'm assuming it's non-obstructive. The elevated EtCO2…
2014-08-30 08:08:22
Christopher Watford
“Bad heartburn” – 82 y.o. female without chest pain.
Brooks, Firstly, thank you for the warm welcome to the club. Secondly, the Glasgow algorithm's only published sens/spec for AMI is 51.6%/97.6% respectively (Tuscon STEMI Database). I've not been able to find any other publications. The GE Marquette 12SL algorithm has been widely studied, but is much older, and ranges in sensitivity from 48% to…
2014-08-29 16:50:14
CB
57 Year Old Male–Chest Discomfort
Given what he was doing (paint fumes on ladder painting) I would first question if the pain is reproducable. Yes his ekg isn't normal but looks like old inferior MI. And he is hypertensive. 02 a must. Def. would give ASA. First would give morphine and see how his cp and bp are. If still…
2014-08-29 11:37:25

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