ECG Case 084 • LITFL • ECG Top 100 Self-Assessment Quiz

89 yr old female presents with chest pain. She has a history of 2nd degree AV block with PPM in-situ.

Serially ECGs were recorded

ECG 1; on arrival pain 3/10

ECG Case 084a LITFL Top 100 EKG — ECG on arrival; pain 3/10

ECG 2; 60 mins later with a further bout of chest pain 8/10

ECG Case 084b LITFL Top 100 EKG — ECG 2; 60 mins later with further chest pain

Describe and interpret these ECGs

ECG ANSWER – ECG 1

Key features:

Rate 60 bpm
Regular V-paced rhythm
LBBB Morphology
Discordant ST / T wave changes
T waves in leads V2-4 appear prominent
Concordant ST elevation in lead I with a positive QRS
- Subtle and easy to miss

ECG ANSWER – ECG 2

Key features:

Rate 60 bpm
Regular V-paced rhythm
LBBB Morphology
Significant progression of ST and T wave changes
- Massive ST elevation (>5mm) in leads V2-4 also proportionately >25% of QRS depth
- Discordant ST elevation in leads II, III, aVF, V5
  - Significantly more pronounced than on previous ECG
- Concordant ST elevation in leads I and V6

INTERPRETATION and OUTCOME

Sgarbossa positive ECG’s

Dynamic and progressive ST segment changes
Underlying V-paced rhythm with LBBB morphology

The patient was discussed with the cardiology team and taken for angiography.

This showed an acute mid LAD occlusion treated with a bare metal stent. Post angiography echo showed moderate systolic and diastolic dysfunction. She was discharged following a 2 day in-patient stay.

FURTHER READING