ECG Case 078

These ECGs are from a 58 yr old male reviewed in a rural setting, approximately ~2500 km from the nearest tertiary centre. He complained of intermittent atypical chest pain over a period of several weeks without any cardiac risk factors.

At the clinic serial ECGs were performed

  • What do you think of the ECGs ?
  • What advice would you give assuming you were the clinician at the tertiary receiving hospital who was contacted regarding this case ?
ECG 078a LITFL Top 100
First ECG
ECG 078b LITFL Top 100
Second ECG

Describe and interpret these ECGs

ECG ANSWER and INTERPRETATION

ECG 1
Rate:

  • 84

Rhythm:

  • Regular
  • Sinus Rhythm

Axis:

  • Normal (70 deg)

Intervals:

  • PR – Normal (~160-200ms)
  • QRS – Normal (80ms)
  • QT – 340ms (QTc Bazett ~ 390 ms)

Segments:

  • Slight Saddling ST segments leads II, III, aVF

ECG 2

Rate:

  • 66

Rhythm:

  • Regular
  • Sinus Rhythm

Axis:

  • Normal (-15 deg)

Intervals:

  • PR – Normal (~180 ms)
  • QRS – Normal (80ms)
  • QT – 360ms (QTc Bazett ~ 360 ms)

Segments:

  • Slight Saddling ST segments leads I, aVL

Additional:

  • T Wave Inversion Leads III, aVF

Initial interpretation:

  • This ECG was interpreted as having dynamic ST change ? ACS.
  • The patient was anticoagulated and transferred by air, ~2500 km, to a tertiary centre for further management.

CLINICAL PEARLS

…but let’s look again:

  • The answer is somewhat less pathological.
  • There is an axis change between the 2 ECGs which is a little odd
  • Look at the complexes in leads III and you can see not only has the T wave become inverted but so has the P wave and QRS complex
Lead III Inversions
  • Compare leads aVL & aVF between the two ECGs and we can see these leads have been swapped
aVL aVF Swap

The ECG changes are due to a LA / LL lead reversal

  • Leads aVL & aVF swap places
  • Leads I & II swap places
  • Lead III becomes completely inverted
  • Lead aVR remains unchanged
  • No change in the precordial leads

TOP 150 ECG SERIES



Emergency Medicine Specialist MBChB FRCEM FACEM. Medical Education, Cardiology and Web Based Resources | @jjlarkin78 | LinkedIn |

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