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Instructors Collection ECG: Large M.I. In Patient With Wrap-Around LAD

The Patient:   These two ECGs, taken 26 minutes apart, were obtained from a 50-year-old man who complained of sudden onset of chest pain.  He denied history of coronary artery disease. He was Covid-positive, and the rest of his medical history was unremarkable.

ECG No. 1:  This ECG was obtained by paramedics enroute to the hospital.  For your beginner-level students, it will be easy to demonstrate the large ST elevations in V3 through V6. The machine’s measurements at the bottom confirm that this ECG meets any field criteria for ST elevation M.I. “STEMI”.

But there is so much more to see! Taking a methodical approach, and starting with rate and rhythm, we see sinus bradycardia at 57 bpm. Intervals and frontal plane axis are within normal limits. R wave progression in the chest leads is stalled in V1- V3 due to loss of initial r waves (narrow QS). The transition to positive deflections in V4 – V6 is abrupt.  These q waves in the V1 and V2 appear narrow, but V3 appears to have a Q wave that is almost wide enough to be considered pathological.  Narrow Q waves may be a transient sign of injury, while wide ones (>40 ms) are an ECG sign of necrosis.

A very visible finding on this ECG is the hyperacute T waves. Hyperacute T waves are defined by comparison to the patient’s normal T waves, if possible. But a general description is broad-based, symmetrical T waves that are unusually tall in comparison to the QRS complex and to the patient’s previous T waves. In this tracing, we see hyperacute T waves in just about all leads.  Hyperacute T waves are a very early sign of subendocardial ischemia in a patient with coronary artery occlusion, and the sign doesn’t last long.

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ECG Basics: Second-degree AV Block, Type I

This two-lead rhythm strip shows a normal sinus rhythm at about 63 bpm.  The P waves are regular. After the sixth P-QRS, there is a non-conducted P wave.  The normal rhythm then resumes.  The two most common reasons for a non-conducted P wave in the midst of a normal sinus rhythm are 1) non-conducted PAC, and 2) Wenckebach conduction. The first is easy to rule out.  The non-conducted P wave is not premature, so it is not a PAC.  The second one is a little harder when we only have a short strip to look at.  We are conditioned to look for progressively-prolonging PR intervals until a QRS is "dropped".  In this case, the progression is in very tiny increments that are hard to see unless you zoom in and measure.  But they ARE progressively prolonging.  An easy hack:  measure the last PRI before the dropped beat and the first one after the pause.  You will see that the cycle ends on a longer PRI (about .28 seconds) and the new cycle starts up with a PR interval of about .20 seconds.  Fortunately, this conduction ratio will have very little effect on the patient's heart rate.

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Ask The Expert

Dr. Jerry W. Jones, MD, FACEP, FAAEM has graciously shared with us his four-part article on the topic of “Delays & Blocks Involving the Bundle Branches”.

Dr. Jones is a talented instructor who makes difficult topics easy.  Please feel free to post your comments and questions for Dr. Jones and our other ECG Gurus. 

Click THIS LINK for a downloadable pdf of Part 1: Non-Specific Intraventricular Conduction Delays. 

Click THIS LINK for a downloadable pdf of Part 2: Left Bundle Branch Block.

Click THIS LINK for a downloadable pdf of Part 3: Right Bundle Branch Block.

Click THIS LINK for a downloadable pdf of Part 4: The Fascicles of the Left Bundle Branch 

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ECG Glossary from Dr. Ken Grauer

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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1924:  Willem Einthoven wins the Nobel prize for inventing the electrocardiograph.

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