ECG Case 108 — LITFL ECG

59yr old male who presented to the Emergency Department following 2 episodes of syncope. He had a long history of infrequent unexplained syncope over the prior 15 years.

His only past medical history is diet controlled T2DM and he was taking no regular medications.

ECG on presentation

** NOTE this is a non-diagnostic ECG recording as it was generated retrospectively from the rhythm telemetry unit

Describe and interpret this ECG

ECG ANSWER and INTERPRETATION

Key features:

Sinus rhythm rate ~90 bpm
Left axis deviation
RBBB Morphology
Prominent T waves and ST elevation in leads II, III, aVF, V2-5 with high voltage complexes
- This ECG was generated using the monitor (non-diagnostic) algorithm. The filter applied in this mode is 0.5 to 40 Hz which can over- or under-estimate low frequency portions of the ECG including the ST segment.
- The diagnostic algorithm filter performs at 0.05 to 150 Hz.
- For a somewhat complicated overview of ECG filtering check out:
Borderline 1st degree AV block

Interpretation:

Bifascicular Block
Borderline PR prolongation
Requires cardiology referral for monitoring and consideration of PPM insertion given history of syncope
ST / T wave changes without chest pain or electrolyte abnormality – related to ECG filtering algorithm

ECG with palpitations

The patient complained of palpitations. Due to rate and rhythm change a rhythm strip was automatically generated

ECG ANSWER and INTERPRETATION

Key features:

Atrial rate 136 bpm
Ventricular rate 27 bpm
AV Dissociation
Broad Complex QRS

Impression:

Complete heart block
Ventricular escape rhythm

Interpretation:

Compared with rhythm strip above
Complete heart block
AV Dissociate with ventricular escape rhythm, rate 24 bpm
Slowing of atrial rate now ~115 bpm

CLINICAL OUTCOME

What happened next?

The patient was treated with atropine followed by isoprenaline infusion.

The next day he underwent an uneventful dual chamber PPM insertion. A subsequent echo showed was normal with an ejection fraction of 64%.

On review of his medical records prior ECG’s had shown alternating left and right bundle branch blocks confirming progressive conducting system disease.