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Instructor Collection ECG: Anterior M.I. and Left Ventricular Hypertrophy

Submitted by Dawn on Sat, 11/16/2024 - 19:12

The Patient:  Sixty-year-old man with a complaint of severe substernal chest pain. Denies hx of M.I., but reports feeling short of breath on exertion for about a year.  Hx of hypertension, but admits he is non-compliant with his medication.  Appears pale and diaphoretic, BP 110/68.

The ECG:  The rhythm is sinus at 62 bpm.  The QRS is slightly wide at 110 ms (.11 seconds), but still within normal limits.  The intervals are WNL.  The frontal plane axis is slightly leftward, while still normal.  The QRS complexes are tall, especially on the left side.  The voltage meets criteria for left ventricular hypertrophy (LVH). This is also called left ventricular enlargement (LVE).  There are several accepted criteria for determining LVH, and this ECG meets them all.  The V1 S wave plus the V5 R wave equal 52 or 52 mm. There is a slightly increased R wave peak time in V5 and V6 (normal is about one small block).  There is ST depression and T wave inversion in the lateral leads: I, aVL, V6.  This is called the "strain" pattern.  V5 is also a lateral lead, but something else is preventing ST depression.

Note the ST elevation in V1 through V5.  This is acute transmural ischemia, or ST elevation M.I.  The STE in V5 was enough to overcome the STD caused by the LVH. The more modern term for these ECG changes is “OMI”, or occlusion myocardial infarction . https://litfl.com/omi-replacing-the-stemi-misnomer/  This term replaces "STEMI", as it includes myocarial injury with ST elevation and also with other ECG findings that are classified as "STEMI Equivalents". 

We don't have information regarding the patient's outcome, but it is worth mentioning that the BP of 110/68 is probably low for him, and he has poor peripheral perfusion, evidenced by his pale skin and sweating.

Dr A Röschl's picture

NON-CONDUCTED PAC

Submitted by Dr A Röschl on Fri, 11/15/2024 - 01:29

Especially in the social media, one sees again and again similar EKGS like the one shown here with the question: What type of AV block is present here? 2nd degree AVB block type I (Wenckebach) or type II (Mobitz)? It is neither one nor the other!
Here, a PAC can be seen under the blue arrow, which is not conduced because the AV node is still refractory (the refractory period of the AV node depends on the preceding heart rate). Therefore, it is not an AV block, but a physiologically non conducted PAC.

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ATRIAL TACHYCARDIA WITH PARTLY ABERRANT CONDUCTION

Submitted by Dr A Röschl on Fri, 11/15/2024 - 01:17

This ECG comes from Germany, where unfortunately recording is still often done at 50 mm/s. Nevertheless, I believe that you can easily recognize the important changes in this ECG, even if you are not familiar with this recording format. The first two beats are the limb leads, the other beats are the precordial leads. The explanation of the visible ECG changes can be found in the 2nd diagram

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VENTRICULAR TACHYCARDIA, ATRIAL FIBRILLATION AND ABERRANT CONDUCTION

Submitted by Dr A Röschl on Fri, 11/15/2024 - 01:06

It is not uncommon for several different abnormal changes to occur simultaneously in an ECG, as in this Holter ECG strip. The explanation of the visible ECG changes can be found in the 2nd image

Dr A Röschl's picture

WHY IS THIS A PVC?

Submitted by Dr A Röschl on Tue, 11/12/2024 - 02:29

The answer to the question is relatively simple. A premature atrial contraction (PAC) is usually characterized by the occurrence of a premature P wave. If the premature P wave is conducted, it is followed by a premature QRS complex. A premature VENTRICULAR contraction (PVC) is a premature beat from the ventricles with a wide QRS complex. A PVC will not have a P wave ASSOCIATED with it. There may be NO P wave before the QRS, or there may be an UNRELATED P wave present. The sinus P wave may be present if the PVC occurs just after the P, but before a normal QRS can result.

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Ask The Expert

Submitted by Dawn on Thu, 10/24/2024 - 13:41

 

Is there a quick and easy way to screen for limb lead wire misplacement?

 Today's expert is Dr. Jerry W. Jones, MD

                                         Dr Jones is known for his Master Classes in Advanced ECG Interpretation, through his company, Medicus of Houston, as well as his published texts, Getting Acquainted With Wide Complex Tachycardias, Getting Acquainted With Laddergrams, and Getting Acquainted With Ischemia and Infarction. His books are available on Amazon.com and on BarnesAndNoble.com. Dr. Jones provides a wealth of free, high-quality ECG instruction on his webpage, and offers tutoring via Zoom. He is a sought-after instructor who is well-known for his celebrated ability to explain complex concepts so that they become understandable and manageable.

 

                                        

OPEN THE RESOURCE LINK BELOW FOR YOUR COPY OF THIS ARTICLE

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For Fans of Dr Jerry W Jones

Submitted by Dawn on Sat, 08/10/2024 - 16:53

“Jerry W. Jones, MD FACEP FAAEM is pleased to announce the move from LinkedIn to his ECG education website: https://medicusofhouston.com/ . Join him there for his popular twice weekly posts on ECG topics for beginners through advanced and announcements regarding his Masterclasses and book releases.” I want to thank all of you for your interest in my teaching and in electrocardiography. I hope to see you in one of my Masterclasses soon! And I hope to hear from you in my new location! Jerry W. Jones, MD FACEP FAAEM

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New Books From Dr. Jerry Jones

Submitted by Dawn on Mon, 01/01/2024 - 17:26

AVAILABLE NOW at:   AMAZON

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ECG Glossary from Dr. Ken Grauer

Submitted by Dawn on Sat, 06/08/2019 - 14:16

Are you looking for a comprehensive ECG glossary that goes beyond simply defining words? Dr. Ken Grauer, who is the ECG Guru's Consulting Expert, has a Glossary available on his website that explains the terms.  Instructors and students alike will benefit from having this glossary readily available.  The glossary is exerpted from his e-Publication, "A 1st Book On ECGs - 2014", available on Amazon.

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Glossary

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ECG HISTORY:     ECG was first put into clinical use in the early 1900s.  In 1909, it helped diagnose an arrhythmia.  A year later, indications of a heart attack were noted.

 

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