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 2; 7 minutes later
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.
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.
- 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
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Emergency Medicine Specialist MBChB FRCEM FACEM. Medical Education, Cardiology and Web Based Resources | @jjlarkin78 | LinkedIn |