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IVCD

Instructors' Collection ECG: Anterior-lateral M.I. With Wide QRS

Tue, 11/12/2019 - 23:56 -- Dawn

The Patient:  An elderly man presents with chest pain, pallor, diaphoresis and weakness.

The ECG:     The rhythm is normal sinus at a rate of about 76 bpm with normal intervals. The QRS complexes are wide at about .14 seconds (140 ms).  There is ST segment elevation in all precordial leads, except for possibly V6.  The shape of the ST segments in the anterior wall range from coved upward in a “frowning” shape (V1) to very straight (V5 and V6).  There is also ST elevation in aVL with ST straightening in Lead I.  There is ST depression in the inferior leads, II, III, and aVF.  Lead II is equally biphasic while I and aVL are positive, indicating an axis that is shifted slightly to the left.  With his symptoms and this alarming ECG, he was sent promptly to the cath lab.

Interpretation:  The rather obvious ST-elevation M.I. is extensive, covering the entire anterior wall, and extending into the high and low lateral walls . This was confirmed in the cath lab, as the patient had an occlusion of the left anterior descending artery near the bifurcation of the circumflex.  The wide QRS meets the criteria for left bundle branch block (wide QRS, negative QRS in V1 and positive QRS in V6 and Lead I).  However, it doesn’t have the “look” of LBBB with the low-voltage seen in the anterior wall. After the offending artery was opened and stented, the wide complex became narrow and was considered to be an interventricular conduction delay that was due to the ischemia.  The ST depression in the inferior wall is most likely reciprocal.

Wide QRS Complex With First-degree AV Block

Fri, 06/07/2019 - 14:48 -- Dawn

The Patient:  This ECG was taken from a 73-year-old man with a history of heart failure with preserved ejection fraction, severe left ventricular hypertrophy, Type II diabetes, and stage 4 chronic kidney disease.  He also suffered deep vein thrombosis and is on anticoagulation.  He has a recent diagnosis of IgA myeloma.  He presented with a complaint of nausea and vomiting and was found to have a worsening of acute kidney infection.  There was suspicion of renal and cardiac amyloidosis, but the patient refused biopsy to confirm this.  He was started on chemotherapy for multiple myeloma and will be followed as an outpatient.

The ECG:  The rhythm is sinus at around 60 bpm, although the rate varies a little at the beginning of the strip.  The QRS complex is wide at .12 seconds, or 120 ms., representing interventricular conduction delay (IVCD).  The PR interval is .32 seconds, or 320 ms. This constitutes first-degree AV block.  There is left axis deviation in the frontal plane and poor R wave progression in the horizontal plane.

Instructors' Collection ECG: Wide QRS Complex With First-degree AV Block

Fri, 06/07/2019 - 13:40 -- Dawn

The Patient:  This ECG was taken from a 73-year-old man with a history of heart failure with preserved ejection fraction, severe left ventricular hypertrophy, Type II diabetes, and stage 4 chronic kidney disease.  He also suffered deep vein thrombosis and is on anticoagulation.  He has a recent diagnosis of IgA myeloma.

Atrial Fib To Cardiac Arrest

Sun, 07/03/2016 - 14:31 -- Dawn

A paramedic crew responded to the office of a local physician. A 61-year-old male presented with a one-week history of chest pain and shortness of breath. He had a previously undiagnosed atrial fibrillation with rapid ventricular response and left bundle branch block, but was alert. Shortly after transport commenced, the patient became unresponsive with Torsades de Pointes, which rapidly degenerated into ventricular fibrillation. The paramedic placed pads and defibrillated within one minute.  After two minutes of compressions, the patient had a fairly regular rhythm with return of spontaneous circulation.  Transport time was short.  On catheterization, the patient was found to have severe coronary artery disease, requiring coronary artery bypass graft surgery (CABG) A balloon pump was inserted in an attempt to strengthen him for surgery.

What is the rhythm?   The 12-lead ECG presented here shows atrial fibrillation at a rate of 138 per minute.  The rhythm is irregularly-irregular with no P waves.  Since the patient had not yet been diagnosed with atrial fib, obviously no therapy had been initiated to control the rate. There is a PVC near the end of the strip.

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