ECG Case 092

33 year old male presents with shortness of breath and dizziness during an indoor soccer game.

Two ECGs were taken, seven minutes apart

ECG 1; on arrival

ECG Case 092a LITFL Top 100 EKG

ECG 2; 7 minutes later

ECG Case 092b LITFL Top 100 EKG

Describe and interpret these ECGs

ECG ANSWER – ECG 1

Rate:

  • 78

Rhythm:

  • Regular
  • Sinus Rhythm

Axis:

  • Normal (65 deg)

Intervals:

  • PR – Short (~100-110 ms)
  • QRS – Prolonged (120ms)
  • QT – 360ms (QTc Bazett ~ 410 ms)

Segments:

  • Discordant ST depression V2-5, II, III, aVF
  • Minor discordant ST elevation aVR, aVL

Additional:

  • Delta wave – slurred upstroke of QRS complexes best seen V2-6, II, III, aVF
  • Negative QRS deflection aVL – pseudo-infarction pattern
  • T Inversion V1-5, II, III, aVF
  • Prominent R waves – R/S > 1 in Lead V1 – likely pseudo-hypertrophy

Interpretation:

  • Wolff-Parkinson-White (Type A Pattern) 
  • …whilst the ST changes are most likely due to WPW we should consider the possibility of ischaemia / infarction. Remember serial ECGs and clinical correlation.

See also this article by Khan et al. which goes through two cases and looks at the patterns of pseudo-hypertrophy and pseudo-infarction that can accompany WPW.

  • Khan IA, Shaw IS. Pseudo ventricular hypertrophy and pseudo myocardial infarction in Wolff-Parkinson-White syndrome. Am J Emerg Med. 2000 Nov;18(7):807-9. PMID: 11103733

ECG ANSWER – ECG 2

Rate:

  • 72

Rhythm:

  • Regular
  • Sinus Rhythm

Axis:

  • Normal (~40 deg)

Intervals:

  • PR – Normal (~200ms)
  • QRS – Normal (80-100ms)
  • QT – 320ms (QTc Bazett ~ 350 ms)

Segments:

  • Slight Concave ST Elevation V1-3

Additional:

  • U Waves V2-4
  • Notching of QRS Complexes seen best in V3, III
  • Q wave aVL looks >25% of associated R wave
  • Compared with ECG 1; resolution of features of WPW

Interpretation: 

  • Intermittent Pre-Excitation

CLINICAL PEARLS

There is a great case review of intermittent pre-excitation during sedation by Wakita el al which includes a review of some of the literature. Wakita et al quotes the incidence of intermittent pre-excitation to be between 20 – 60% of all cases of WPW.

  • Wakita R, Takahashi M, Ohe C, Kohase H, Umino M. Occurrence of intermittent Wolff-Parkinson-White syndrome during intravenous sedation. J Clin Anesth. 2008 Mar;20(2):146-9. PMID: 18410873

FURTHER READING
  • ECG Library – Pre-excitation Syndromes
  • Eponymictionary – Wolff-Parkinson-White
  • Wakita R, Takahashi M, Ohe C, Kohase H, Umino M. Occurrence of intermittent Wolff-Parkinson-White syndrome during intravenous sedation. J Clin Anesth. 2008 Mar;20(2):146-9. PMID: 18410873
  • Khan IA, Shaw IS. Pseudo ventricular hypertrophy and pseudo myocardial infarction in Wolff-Parkinson-White syndrome. Am J Emerg Med. 2000 Nov;18(7):807-9. PMID: 11103733

TOP 150 ECG SERIES



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

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