ECG Case 115

Rate:

• Mean rate 66 bpm

Rhythm:

• Sinus rhythm
• Unifocal PVCs

Axis:

• Normal

Intervals:

• PR – Normal (~200ms)
• QRS – Prolonged (120-130 ms)
• QT – 410ms (QTc Bazett 470 ms)

Additional:

• QRS fragmentation 
  • Best seen leads V2-3
  • Lead V2 rsr’s’r”s” pattern
  • Lead V3 rsr’s’ pattern
• T wave inversion leads V4-5
• ST elevation leads aVR and aVL (< 1mm)<1mm font=””>
• ST depression leads II, III, aVF

Interpretation:

• ST and T wave changes
  • Likely ACS given history 
  • Needs serial ECGs and comparison with prior ECGs
• QRS Fragmentation
  • Caused by abnormal ventricular repolarisation
  • Due to myocardial scarring, fibrosis or ischaemia

QRS Fragmentation

The two following papers are a great overview of QRS fragmentation including diagnostic morphology and clinical relevance in terms of associations and effects on morbidity and mortality.

Further reading:

• Jain R, Singh R, Yamini S, Das MK. Fragmented ECG as a Risk Marker in Cardiovascular Diseases. Curr Cardiol Rev. 2014; 10(3): 277–286.
• Mittal SR. Fragmented QRS: A simple electrocardiographic prognostic marker in cardiovascular disease. J Clin Prev Cardiol 2016; 5: 94-8