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
Brooks Walsh MD
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Very interesting discussion - I had not anticipated the degree to which giving/not giving nitro would be controversial! I had my own agenda in presenting this case, but I think it would be better to follow the interest of our readers. I'll add a few pearls about ACS, nitro, and inferior STEMIs in my discussion…
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Sassy
“Bad heartburn” – 82 y.o. female without chest pain.
Our local protocols prevent administration of GTN to RVI, Inferior STEMI with BP less than 160 systolic or HR less than 50bpm. As more than 50% of inferior MI's have RV involvement you walk a very fine line between preload and none. The HR could possibly indicate RCA occlusion so there's one side of your…
2014-08-20 22:23:14
Jonathan
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*Strongly consider withholding GTN and Morphine which could decrease venous return.
2014-08-20 21:22:02
Paul
“Bad heartburn” – 82 y.o. female without chest pain.
Screw it. I'm giving NTG/GTN. I give everybody at least 1. Not every IWMI will lose their BP from NTG. Likewise, I've even had a few RVMIs that I gave NTG/GTN to who actually improved quite a bit. Don't withhold treatment "just because." Use clinical judgement. I don't think you can do that by withholding…
2014-08-20 21:07:31
Jonathan
“Bad heartburn” – 82 y.o. female without chest pain.
ST elevation II, III, aVF Inferior Infarct requires repeat ECG with V4R to check for right ventricular infarct. If this is the case then a fluid bolus may be indicated to increase venous return to the left ventricle. RCA occlusion is the most likely cause. Right ventricular infarcts can present with symptomatic bradycardia. Aspirin, GTN…
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