Name that ECG: 66 year old female – Findings

This is the conclusion to our Name that ECG case: 66 year old female, resolved chest pain.

66 year old female, resolved chest pain.

Name that ECG: 66 year old female

 

Rhythm:

  • Rate: atrial rate of ~55 bpm, ventricular rate of ~55 bpm
  • Regularity: regular
  • P-waves: sinus (upright in I and II), associated 1:1 with the QRS
  • PRi: 140 ms
  • QRS duration: 90 ms

Bonus points:

  • Axis: -45 degrees, left axis deviation, LAFB
  • Bundle Branches: normal conduction
  • QTc: normal (<1/2 R-R interval), 420 ms (Bazett's Formula)
  • ST/T-waves:
    • T-waves: flipped T-waves in aVL, biphasic V2-V5 consistent with Wellen's Syndrome
    • ST-elevation: none noted
    • ST-depression: none noted

Differentials:

  • Normal sinus rhythm in a patient with Wellen's Syndrome
    • Possible high-grade stenosis of the LAD with recent reperfusion

Notes:

  • Wellen's Syndrome should be regarded with the same importance as a STEMI during assessment and transport.

1 Comment

  • VinceD says:

    If you wanted to really push the limits of this ECG I also see inverted inverted U-waves in leads V2-V4, I, and aVL. They're super faint and I wasn't sure if I believed them at first, but measuring from the QRS to the U wave in III and aVF and transposing that interval to the other leads proves that it's really them.

    They don't add any information the T-waves don't tell you here, but heck, they're there.

    And now I'm really being a pain, but I think calling a LAFB is being a little generous to that LAD.  By my eye I put the axis, at most, at around -40 degrees. There's also no well developed rS complexes in II and aVF and the tracing lack the poor R-wave progression I usually see in true LAFB's. There doesn't seem to be an accepted criteria for making the Dx, but this one seems to be pushing it.

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EMS 12-Lead

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Comments
Kevin
44 year old male CC: Palpitations
Why on earth would you risk VF, by giving Adenosine to rule out rhythms.. This is dangerous, and foolish. There might be a slight chance that this is WPW.. You might as well just give him Cardizem, they are both AV nodal blockers... I don't know why the AHA even added this stupid idea..
2014-10-22 13:31:06
Vince DiGiulio
The 360 Degree Heart – Part II
It is standard practice in electrocardiography to label the first 90 degrees counter-clockwise from "zero" that way. When you see a patient with "left axis deviation" you'll see that their measured QRS axis is somewhere between -30 and -90 degrees. Imagine if you saw someone with a mean QRS axis at 5 degrees. Now imagine…
2014-10-21 14:00:37
Bryan
The 360 Degree Heart – Part II
I don't understand why (-)III and aVL are be labeled -60 and -30 degrees instead of 300 and 330 degrees?
2014-10-21 13:43:29
The 360 Degree Heart – Part II | EMS 12 Lead
The 360 Degree Heart – Part I
[…] first post in our “360 Degree Heart” series attempted to visualize how the different frontal plane […]
2014-10-21 12:50:56
Eric Strong
Axis Determination – Part VI
This is a great discussion of axis determination. One minor suggestion: I think it's potentially misleading to refer to an axis between 0 and -30 as "physiologic left axis deviation", since "axis devitation" implies deviation from normal, and axes between 0 and -30 are perfectly normal, (depending on age and body habitus). It may be…
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