ECG Case 087

Rate:

• ~115 bpm

Rhythm:

• Regular
• Sinus Rhythm

Axis:

• Normal

Intervals:

• PR – Normal (~160ms)
• QRS – Normal (100ms)
• QT – 320ms

Segments:

• ST elevation leads aVR (<1mm), V1 (1mm), V2 (2mm)
• ST depression lead I

Additional:

• Biphasic T wave leads aVF & V3
• T wave inversion leads I, II, aVL and deep inversion leads V4-6
• Voltage criteria for LVH
  • S V2 (25mm) + R V6 (20mm)
• R wave peak time in leads V5 & V6 ~60ms
• P waves wide with deep terminal deflection in lead V1 with notching in lead II

Interpretation:

• Sinus tachycardia
• ECG features for:
  • LVH
  • LAE
• Deep anterolateral T wave inversion

Broad differentials

These ECG features could be seen in a wide range of conditions and include:

• Ischaemia
• Myocarditis
• Acid-base / electrolyte disturbance
• Raised ICP

The key to interpretation of any ECG, or any test for that matter, is looking at the test and then taking it back to the patient in question.

In this case we have a young male with no acute cardiac complaint, i.e. nil chest pain, dyspnea, and a known cardiac condition. Given these factors the most likely cause is apical hypertrophic cardiomyopathy (AHCM) given the absence of Q waves and deep T wave inversion in the precordial leads, this patient did in fact have known apical hypertrophic cardiomyopathy.

You can read more about apical hypertrophic cardiomyopathy in the links below:

• ECG Library – Hypertrophic Cardiomyopathy (HCM)
• Madias JE. Electrocardiogram in apical hypertrophic cardiomyopathy with a speculation as to the mechanism of its features. Neth Heart J. 2013 Jun;21(6):268-71. [PMC3661871]
• Yıldırım MN, Selçoki Y, Eryonucu B. Apical Hypertrophic Cardiomyopathy. Eur J Gen Med 2010;7(2):206-209