December EKG

You know the drill — write your best interpretations below, fabulous prizes and glory await to the best one!

8 Responses

  1. Faysal

    Sinus rhythm
    Rate of ~110
    Incomplete RBBB
    S1,Q3,T3 pattern
    Deep S in leads V1-3 suggestive of LVH.
    TWI in leads V1-4, suggestive of RV strain.
    Long QT
    given the history of SOB, marginal elevation in the troponin, sinus tachy with other EKG finding is concerning for PE

  2. Faysal

    However myocardial infarction is not excluded, will order CTA if the renal function is OK, will trend the troponin and will do an Echocardiogram to check the RVSP and look for any SWMA

  3. Nagarjuna R Gujjula

    Rate: 110 Bpm ( Tachycardia)
    Rhythm: Normal sinus rhythm
    QRS: 80-100 msec, underlying Rsr pattern consistent with possible underlying RBBB
    ST: No major ST segment elevations or depressions
    T waves: Inversions are noted in the II/III/aVF, V2-V5 with possible RV strain
    Slight ST depressions with T wave inversions in the lateral leads (V5-V6) consistent with LV strain seen with underlying LVH
    PR: Normal range (< 200 m sec) no AV blocks noted
    QT: QT interval is about 10 small squares which is equal to 400 m sec, which is in normal range.
    S1Q3T3 pattern is evident.

    69 yo Male with new onset SOB for 3 days is concerning for possible ACS given his sex and age group. We don't have further medical history of past coronary events. Given that we consider SOB as anginal equivalent which is supported by his Trop elevation, I will admit him to CCU and trend troponin's. We can consider D dimer vs CTA depending upon the pretest probability and renal functions to rule out PE given the strain pattern, sinus tachycardia and SOB. If his troponin is trending up will start him on Heparin drip for possible NSTEMI. ASA, BB and statin if not given.

    Bedside Echo will give us more window of opportunity to see if patient have RV strain(McConnell's sign), septal bowing towards left side or any wall motion abnormalities with EF estimation.


  4. Abhi

    Sinus tachycardia with Heart rate >100.
    – S1Q3T3
    – Incomplete RBBB
    – t wave inversions in lead II, III, aVF, V1 to V4 with no reciprocal changes more concerning for Right ventricular strain pattern

    All the above EKG changes and non specific maker like elevated troponin make Acute pulmonary embolism more likely.
    Nstemi will be the other differential
    Faysal got most of them correct.
    No prolonged QT and questionable LVH(less likely)

    Plan will be to do CTA and Start Heparin drip
    Even if CTA is negative, we can start him on heparin drip considering NSTEMI. Will do anEchocardiogram and Start on ASA, high intensity statin and Beta blocker

  5. Faysal

    QT interval shortens at faster heart rates, so you need to calculate the QTc, which corrects the QT at the given HR to the QT at a heart rate of 60.
    If you correct the QT for the HR using this equation QTC = QT + 1.75 (heart rate – 60) => 400+1.75 (50) then the corrected QTc will be ~487 msec, (up to 542 msec when I used other formulas).
    and as we know QTc is prolonged if > 440ms in men or > 460ms in women.

  6. Aiman Smer

    Great job everyone, this was nice example of ECG manifestations of PE, sinus tach with S1Q3T3 and TWI in the right precordial leads indicates RV strain. This was supported by elevated troponin..! This patient had an extensive bil LE DVTs and PE. Actually, his echo was impressive and showed large thrombus in transit going from the RA to LA via PFO..!

    Well done to all of you..!


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