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 ?

Describe and interpret these ECGs

ECG ANSWER and INTERPRETATION

ECG 1
Rate:

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:

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