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A Prescription for Trouble
ANSWER
The correct interpretation includes normal sinus rhythm, right atrial enlargement, left ventricular hypertrophy, and a prolonged QT interval. Normal sinus rhythm is indicated by a P for every QRS and a QRS for every P, with a constant PR interval (see rhythm strip of lead I).
Right atrial enlargement is evidenced by the tall P waves in leads II, III, aVF, and V1. Note that there is no biphasic P wave in lead V1, so there is no evidence of accompanying left atrial enlargement.
High-voltage limb leads (sum of R in lead I and S in lead III ≥ 25 mm) or precordial leads (sum of S in V1 and R in V5 or V6 ≥ 35 mm) are indicative of left ventricular hypertrophy.
The QTc interval of 653 ms with a normal sinus rate is worrisome for prolonged QT syndrome. A review of the history shows the patient to be taking two drugs (lithium, azithromycin) known to prolong the QT interval. Although it is not known whether this patient has inherent QT prolongation, use of these types of agents should be avoided.
ANSWER
The correct interpretation includes normal sinus rhythm, right atrial enlargement, left ventricular hypertrophy, and a prolonged QT interval. Normal sinus rhythm is indicated by a P for every QRS and a QRS for every P, with a constant PR interval (see rhythm strip of lead I).
Right atrial enlargement is evidenced by the tall P waves in leads II, III, aVF, and V1. Note that there is no biphasic P wave in lead V1, so there is no evidence of accompanying left atrial enlargement.
High-voltage limb leads (sum of R in lead I and S in lead III ≥ 25 mm) or precordial leads (sum of S in V1 and R in V5 or V6 ≥ 35 mm) are indicative of left ventricular hypertrophy.
The QTc interval of 653 ms with a normal sinus rate is worrisome for prolonged QT syndrome. A review of the history shows the patient to be taking two drugs (lithium, azithromycin) known to prolong the QT interval. Although it is not known whether this patient has inherent QT prolongation, use of these types of agents should be avoided.
ANSWER
The correct interpretation includes normal sinus rhythm, right atrial enlargement, left ventricular hypertrophy, and a prolonged QT interval. Normal sinus rhythm is indicated by a P for every QRS and a QRS for every P, with a constant PR interval (see rhythm strip of lead I).
Right atrial enlargement is evidenced by the tall P waves in leads II, III, aVF, and V1. Note that there is no biphasic P wave in lead V1, so there is no evidence of accompanying left atrial enlargement.
High-voltage limb leads (sum of R in lead I and S in lead III ≥ 25 mm) or precordial leads (sum of S in V1 and R in V5 or V6 ≥ 35 mm) are indicative of left ventricular hypertrophy.
The QTc interval of 653 ms with a normal sinus rate is worrisome for prolonged QT syndrome. A review of the history shows the patient to be taking two drugs (lithium, azithromycin) known to prolong the QT interval. Although it is not known whether this patient has inherent QT prolongation, use of these types of agents should be avoided.
A 74-year-old man is admitted to your service with gastrointestinal bleeding. He has a history of diverticulitis and has had multiple episodes in which he passed bright red blood per rectum, sufficient to warrant blood transfusion. The last episode occurred about 14 months ago. The current one started 12 hours ago; he presents to the emergency department per your instructions. Medical history is remarkable for hypertension, hypothyroidism, and prostatic hypertrophy. He has no prior cardiac history. Surgical history is remarkable for an appendectomy, cholecystectomy, and left rotator cuff repair. He has a positive psychiatric history of bipolar disorder that has been treated with lithium for more than 40 years. The patient retired after working as a welder for 50 years. He is currently married to his second spouse. He has a 60-pack-year history of cigarette smoking and drinks one glass of bourbon per day. He denies using recreational drugs. Family history reveals that his mother died of a stroke at age 97, and his father died of natural causes at 102. The patient has three brothers, all of whom are alive and well. One brother had an MI followed by coronary artery bypass grafting at age 71; the other two brothers’ medical histories are unknown. Current medications include furosemide, metoprolol, l-thyroxine, tamsulosin, and a daily baby aspirin. Three days ago, he started a prescription of azithromycin for an upper respiratory infection (URI) diagnosed at a local urgent care center. Review of systems is positive for a URI manifest by fever, productive cough, and end-expiratory wheezing. The patient says this has improved considerably since initiation of antibiotic therapy. He also says that lithium has held his manic episodes in check for years, and he has refused several attempts to wean him from it. He still experiences urinary hesitancy and frequency despite starting tamsulosin; he has an appointment with a urologist in four weeks to discuss other options. The remainder of the review of systems is unremarkable. Laboratory data upon admission include a hematocrit of 38.2% and a white blood cell count of 11.0 cells/dL. All other lab values are within normal limits. The admission ECG reveals a ventricular rate of 69 beats/min; PR interval, 188 ms; QRS duration, 100 ms; QT/QTc interval, 610/653 ms; P axis, 55°; R axis, 21°; and T axis, 103°. What is your interpretation of this ECG?
Interpretation: Humans, 1; Machine, 0
ANSWER
The correct interpretation of this ECG is atrial fibrillation with a rapid ventricular response and aberrantly conducted QRS complexes. The latter were misinterpreted as ventricular tachycardia. Although they represent a wide complex at a rate of more than 100 beats/min, the rhythm is irregular and the intrinsic (initial) inflection of normally conducted and aberrant beats is the same. (See lead I rhythm strip at bottom.)
What is unusual (and doesn’t make sense) regarding this ECG is the machine’s reading of the PR interval (128 ms) and the QRS duration (88 ms). For one thing, there is no measurable PR interval. And for another, the measured QRS duration accounts for the normally conducted complex and not the aberrantly conducted ones.
The technician was reassured, and the patient underwent successful cardioversion back to normal sinus rhythm.
ANSWER
The correct interpretation of this ECG is atrial fibrillation with a rapid ventricular response and aberrantly conducted QRS complexes. The latter were misinterpreted as ventricular tachycardia. Although they represent a wide complex at a rate of more than 100 beats/min, the rhythm is irregular and the intrinsic (initial) inflection of normally conducted and aberrant beats is the same. (See lead I rhythm strip at bottom.)
What is unusual (and doesn’t make sense) regarding this ECG is the machine’s reading of the PR interval (128 ms) and the QRS duration (88 ms). For one thing, there is no measurable PR interval. And for another, the measured QRS duration accounts for the normally conducted complex and not the aberrantly conducted ones.
The technician was reassured, and the patient underwent successful cardioversion back to normal sinus rhythm.
ANSWER
The correct interpretation of this ECG is atrial fibrillation with a rapid ventricular response and aberrantly conducted QRS complexes. The latter were misinterpreted as ventricular tachycardia. Although they represent a wide complex at a rate of more than 100 beats/min, the rhythm is irregular and the intrinsic (initial) inflection of normally conducted and aberrant beats is the same. (See lead I rhythm strip at bottom.)
What is unusual (and doesn’t make sense) regarding this ECG is the machine’s reading of the PR interval (128 ms) and the QRS duration (88 ms). For one thing, there is no measurable PR interval. And for another, the measured QRS duration accounts for the normally conducted complex and not the aberrantly conducted ones.
The technician was reassured, and the patient underwent successful cardioversion back to normal sinus rhythm.
A 72-year-old woman with recurring palpitations and a rapid heart rate presents for evaluation stating that her heart started racing early yesterday morning. It began while she was sleeping, which is normal for her, but while the problem usually resolves within hours, this time it lasted longer. She had an MI about seven years ago, at which time she was told she had atrial fibrillation. Since then, she has had multiple episodes requiring cardioversion and suspects that is what is required this time. She has brought along a copy of her baseline ECG, which shows normal sinus rhythm, an old inferior MI, and an intraventricular conduction delay. Her history includes hypertension, hyperlipidemia, and diabetes. Surgical history is remarkable for coronary stenting (right coronary artery, first diagonal coronary artery, and an obtuse marginal coronary artery). She also has a remote history of hysterectomy and appendectomy. Her current medications include metoprolol, atorvastatin, amiodarone, metformin, and glyburide; she takes an OTC stool softener daily. She is allergic to sulfa. The patient, a retired schoolteacher and the matriarch of her church, is married and has two grown children. She has two siblings, both of whom have diabetes and hypertension. She smoked 1.5 packs of cigarettes per day until her MI, at which point she quit. She does not drink alcohol and has never used recreational drugs. Review of systems is positive for increasingly worsening eyesight, particularly halos around lights at night; she says she was told this might happen when she started taking amiodarone. She has intermittent episodes of diarrhea that she attributes to the stool softener, adding that she considers this consequence “better than the alternative.” The rest of the review is unremarkable. Vital signs include a blood pressure of 148/92 mm Hg; pulse, 140 beats/min and irregular; temperature, 98.4°F; and O2 saturation, 97% on room air. She is 64 in tall and weighs 169 lb. Physical exam reveals a very spry-appearing woman in no distress; in fact, she jokingly complains that she’s too young to have “old people’s diseases” and proudly points out that she has no symptoms of arthritis or dementia. She wears corrective lenses and hearing aids. The exam reveals no thyromegaly or jugular venous distention; clear lung fields; and an irregularly irregular heart rate of 146 beats/min. Her heart rate is too rapid to assess for murmurs or extra heart sounds. The abdomen is benign, and the patient has strong bilateral peripheral pulses in all extremities. The neurologic exam is intact. Suspecting that the patient is in atrial fibrillation, you ask the new ECG technician to obtain a reading. Five minutes later, he calls for help because “the patient is in ventricular tachycardia.” But when you walk into the room, the patient looks quite comfortable on the exam table and exhibits no distress. Reviewing the ECG, you note a ventricular rate of 152 beats/min; PR interval, 128 ms; QRS duration, 88 ms; QT/QTc interval, 280/445 ms; P axis, 27°; R axis, 23°; and T axis, 232°. What is your interpretation of this ECG—and what findings are inconsistent with the machine’s “interpretation”?
Woman Blacks Out Repeatedly, Doesn’t Remember Doing So
ANSWER
The ECG shows marked sinus bradycardia with a four-second pause consistent with sinus arrest. This may be due to conduction disease within the sinus node and may be exacerbated by use of β-blockers or calcium-channel blockers, or by hypothyroidism.
The patient’s episodes of near-syncope coincided with sinus arrest on telemetry monitoring. She underwent implantation of a dual-chamber permanent pacemaker and resumed all previous activities without issue.
ANSWER
The ECG shows marked sinus bradycardia with a four-second pause consistent with sinus arrest. This may be due to conduction disease within the sinus node and may be exacerbated by use of β-blockers or calcium-channel blockers, or by hypothyroidism.
The patient’s episodes of near-syncope coincided with sinus arrest on telemetry monitoring. She underwent implantation of a dual-chamber permanent pacemaker and resumed all previous activities without issue.
ANSWER
The ECG shows marked sinus bradycardia with a four-second pause consistent with sinus arrest. This may be due to conduction disease within the sinus node and may be exacerbated by use of β-blockers or calcium-channel blockers, or by hypothyroidism.
The patient’s episodes of near-syncope coincided with sinus arrest on telemetry monitoring. She underwent implantation of a dual-chamber permanent pacemaker and resumed all previous activities without issue.
A 74-year-old woman is transferred from a skilled nursing facility (SNF) for evaluation following three episodes of near-syncope in the past week. Each episode occurred while the patient was “at rest,” sitting at a table playing cards with her fellow residents. The most recent episode, witnessed by a nurse’s aide, occurred this morning. The aide called the nursing supervisor to explain that the patient had been engaged in conversation and then slumped over in her chair for approximately three to four minutes. When her companions shook her, she promptly woke up and continued playing cards as if nothing had happened. Upon questioning, the patient denied experiencing shortness of breath, palpitations, or chest pain. Her statement that “this has never happened before” was promptly corrected by her companions. The patient’s medical history is positive for hypertension, hypothyroidism, cholecystitis, and diverticulitis. There is a remote history of pneumonia. Surgical history is positive for cholecystectomy, hysterectomy, and multiple colonoscopies. The patient’s regular medications include amlodipine, atorvastatin, levothyroxine, and baby aspirin. She is allergic to sulfa. A widow for 11 years, the patient has resided in the SNF for three years and has two sons who visit weekly. She is quite active, serving as chairwoman for many of the facility’s events. She has never smoked but says she “enjoys” a nightly glass of brandy before bed. Review of systems is positive for loose stools and occasional blood secondary to her diverticulitis. She denies palpitations, arrhythmias, tachycardia, or other cardiac symptoms. She wears corrective lenses and hearing aids. Vital signs include a blood pressure of 148/98 mm Hg; pulse, 50 beats/min; respiratory rate, 14 breaths/min; and temperature, 98.8°F. Her weight is 146.3 lb and her height, 58 in. Physical examination reveals a keenly alert, oriented (x 3), and well-nourished woman. Her hearing is intact with her hearing aids in place. There are no indications of carotid bruit, jugular venous distention, or thyromegaly. The lungs are clear in all fields. The cardiac exam is remarkable for a rate of 50 beats/min; the rhythm is regular. There is a grade II/VI systolic murmur over the left sternal border. The abdominal exam reveals well-healed surgical scars. Her abdomen is nontender, and there are no palpable masses. Peripheral pulses are strong and regular in all extremities, and there are minimal signs of osteoarthritis in her hands and fingers. The neurologic exam is intact and unremarkable. As you leave the patient’s room, you ask your new technician to obtain a 12-lead ECG. Shortly thereafter, the tech opens the exam room door, shouting for help. By the time you enter the room, the patient is lying comfortably on the exam table, wondering what is wrong. The tech hands you the ECG, which shows a ventricular rate of 29 beats/min; PR interval, 176 ms; QRS duration, 76 ms; QT/QTc interval, 474/329 ms; P axis, 30°; R axis, 42°; and T axis, 20°. What is your interpretation of this ECG?
Neighbor Finds Man on Knees, Vomiting
ANSWER
The correct interpretation of this ECG includes atrial fibrillation and ST- and T-wave changes consistent with a central nervous system hemorrhage, as well as a markedly prolonged QT interval.
The most common ECG alterations seen in cases of acute subarachnoid hemorrhage include repolarization abnormalities due to imbalance of autonomic cardiovascular control. While ST depression is more common in patients with poor outcomes, it is not predictive.
ANSWER
The correct interpretation of this ECG includes atrial fibrillation and ST- and T-wave changes consistent with a central nervous system hemorrhage, as well as a markedly prolonged QT interval.
The most common ECG alterations seen in cases of acute subarachnoid hemorrhage include repolarization abnormalities due to imbalance of autonomic cardiovascular control. While ST depression is more common in patients with poor outcomes, it is not predictive.
ANSWER
The correct interpretation of this ECG includes atrial fibrillation and ST- and T-wave changes consistent with a central nervous system hemorrhage, as well as a markedly prolonged QT interval.
The most common ECG alterations seen in cases of acute subarachnoid hemorrhage include repolarization abnormalities due to imbalance of autonomic cardiovascular control. While ST depression is more common in patients with poor outcomes, it is not predictive.
A 68-year-old man was found on his knees, vomiting, in his backyard by a neighbor early this morning. When asked if he was OK, the patient responded that he suddenly felt nauseated and had a headache. The neighbor helped him to his feet and, noticing that his left leg and arm were weak, called 911. During that time, the neighbor observed slurred speech. As they waited for the ambulance to arrive, the patient was able to say that this was the worst headache he’d ever had. When the paramedics arrived, they recorded a blood pressure of 198/120 mm Hg, consistent in both arms. Medical history is remarkable for hypertension, paroxysmal atrial fibrillation, adult-onset diabetes, and nephrolithiasis. Surgical history is remarkable for appendectomy, cholecystectomy, and lithotripsy. The patient is a retired civil engineer who lives at home alone. His wife died three years ago of complications from uterine cancer. He has one adult son who is in excellent health but lives on the opposite coast. The patient has never smoked and drinks approximately one six-pack of beer per month. Current medications include hydrochlorothiazide, metformin, and rivaroxaban. He is allergic to sulfa-containing medications. A complete review of systems is not obtained, given the patient’s slurred speech and progressive aphasia. He is able to nod yes or no to specific questions, and no significant symptoms or findings are identified. At the hospital, the patient is agitated and in apparent distress, with severe headache and aphasia. Vital signs include a blood pressure of 180/110 mm Hg; pulse, 60 beats/min; respiratory rate, 14 breaths/min; and temperature, 98.4°F. The O2 saturation is 96.4% on room air. Pertinent physical findings include aphasia, oculomotor nerve palsy, nuchal rigidity, and findings of a left-sided (right hemispheric) progressive hemiparesis. The remainder of the physical examination is noncontributory. Samples are drawn for laboratory testing, and an ECG is obtained prior to the patient’s transfer to radiology for CT of the head. The ECG findings include a ventricular rate of 62 beats/min; QRS duration, 88 ms; QT/QTc interval, 718/728 ms; P axis, not measured; R axis, 35°; and T axis, 209°. What is your interpretation of this ECG?
Marathon Runner Has History of A-fib
ANSWER
This ECG shows marked sinus bradycardia with a first-degree atrioventricular block and nonspecific T-wave abnormality. The QT interval of 524 ms is consistent with prolonged QT interval but is normal when corrected for rate.
These findings were consistent with previous ECGs. Since the patient’s bradycardia is asymptomatic, no intervention (ie, placement of a permanent pacemaker) is indicated.
ANSWER
This ECG shows marked sinus bradycardia with a first-degree atrioventricular block and nonspecific T-wave abnormality. The QT interval of 524 ms is consistent with prolonged QT interval but is normal when corrected for rate.
These findings were consistent with previous ECGs. Since the patient’s bradycardia is asymptomatic, no intervention (ie, placement of a permanent pacemaker) is indicated.
ANSWER
This ECG shows marked sinus bradycardia with a first-degree atrioventricular block and nonspecific T-wave abnormality. The QT interval of 524 ms is consistent with prolonged QT interval but is normal when corrected for rate.
These findings were consistent with previous ECGs. Since the patient’s bradycardia is asymptomatic, no intervention (ie, placement of a permanent pacemaker) is indicated.
A 52-year-old man has a cardiac diagnosis of paroxysmal atrial fibrillation (A-fib). An echocardiogram demonstrates no valvular heart disease and a left ventricular ejection fraction of 62%. There are no symptoms to suggest left ventricular dysfunction or volume overload. He denies exertional angina or dyspnea and says he has had no palpitations or recurrences of A-fib since you saw him six months ago. The patient is very active: In the past year, he has completed two half marathons and one full marathon. In addition to his running schedule, he also swims 30 min/d and trains on an elliptical machine for 1 h/d. His only complaint today is that he recently lost the toenails off each big toe, which he attributes to his running, adding that this isn’t the first time it’s happened. Medical history is remarkable for two episodes of A-fib that manifested with palpitations and a rapid heart rate, which caused dyspnea. The last episode was approximately eight months ago. Both were treated with cardioversion in the emergency department of your institution. He was not started on an anticoagulant or antiarrhythmic medication after either occurrence. The patient currently takes no medications except the occasional ibuprofen for muscle soreness related to training. He has no known drug allergies and does not use naturopathic medications or illicit drugs. He has never smoked, and he only drinks wine socially, usually on weekends. The patient works as a certified public accountant for a large corporation. He is married with two teenage children. A 12-point review of systems is remarkable only for an inguinal rash and the aforementioned missing toenails. On physical exam, the vital signs include a blood pressure of 107/60 mm Hg; pulse, 46 beats/min; respiratory rate, 12 breaths/min-1; and temperature, 97.8°F. His height is 74 in and his weight, 172 lb. The patient is in no distress. The neck veins are flat, the lungs are clear, and the cardiac exam reveals no murmurs or gallops. The abdominal exam is unremarkable. There is no edema in the peripheral extremities, and pulses are strong bilaterally. Both feet reveal multiple callouses, and the two great toes have missing nails but healthy nail beds. The neurologic exam is intact. As part of his clinic visit, a 12-lead ECG is obtained. It reveals a ventricular rate of 38 beats/min; PR interval, 222 ms; QRS duration, 112 ms; QT/QTc interval, 524/416 ms; P axis, 20°; R axis, 26°; and T axis, 33°. What is your interpretation of this ECG?
Leg Swelling Accompanied by Weight Gain
In the past two weeks, a 59-year-old postmenopausal woman has noticed swelling in her legs and a 10-lb weight gain. For the past three days, she has also had a vague, aching pain in the right upper abdominal quadrant, which surprises her, since her gall bladder was removed long ago. There is no prior history of chest pain, dyspnea, or systemic hypertension.
The patient does have a history of paroxysmal atrial fibrillation, palpitations, and pulmonary hypertension. She is chronically obese and has hypothyroidism. Surgical history is significant for cholecystectomy, hysterectomy, and left breast lumpectomy with axillary node dissection.
Her job at a local factory, assembling components for pressure washer pumps, requires her to sit for extended periods. She smokes 1.5 packs of cigarettes per day, a habit that began when she was 16. She drinks one or two beers daily and admits she has “many more” on the weekends. She has used marijuana in the recent past but not in the past month. She denies use of any other illicit drugs or homeopathic medications.
Her medication list includes levothyroxine sodium and ibuprofen. She says she’s “supposed to be taking some kind of heart medication” but hasn’t taken it for several months (and cannot remember the name). It was prescribed for her when she was on vacation in the Florida Keys and experienced similar symptoms. She sheepishly admits to trying her husband’s sildenafil, as she’s been told it works for pulmonary hypertension. She is allergic to sulfa and tetracycline.
Review of systems is remarkable for bilateral hip and ankle pain, which she attributes to her weight. She has had no change in bowel or bladder function. The remainder of the review is unremarkable.
Physical exam reveals a weight of 297 lb and height of 5’6”. Vital signs include a blood pressure of 128/88 mm Hg; pulse, 90 beats/min; respiratory rate, 14 breaths/min-1; temperature, 98.2°F; and O2 saturation, 98.2%.
She is morbidly obese and in no distress. Pertinent physical findings include elevated jugular venous return, bilateral rales in both lung bases, a soft, early diastolic murmur best heard at the left lower sternal border, and a regular rate and rhythm. She also has mild tenderness to deep palpation in the right upper abdominal quadrant. Her lower extremities demonstrate 3+ pitting edema to the level of the knees bilaterally. There are no skin lesions, and the neurologic exam is grossly intact.
As part of her workup, you order an ECG, which reveals a ventricular rate of 94 beats/min; PR interval, 130 ms; QRS duration, 76 ms; QT/QTc interval, 394/492 ms; P axis, 50°; R axis, 80°; and T axis, 47°. What is your interpretation?
ANSWER
Pertinent findings on this ECG include normal sinus rhythm, right atrial enlargement, and a prolonged QT interval. Criteria for right atrial enlargement include P waves > 2.5 mm in leads II, III, and aVF and > 1.5 mm in leads V1 and V2. A prolonged QT interval is evidenced by a QTc > 470 ms using Bazett’s formula (QTc = QT divided by the square root of the RR interval).
The patient’s symptoms and ECG finding of right atrial enlargement coincide with pulmonary hypertension and right-sided heart failure. The prolonged QT interval may be due to her history of hypothyroidism; however, this has not been confirmed.
In the past two weeks, a 59-year-old postmenopausal woman has noticed swelling in her legs and a 10-lb weight gain. For the past three days, she has also had a vague, aching pain in the right upper abdominal quadrant, which surprises her, since her gall bladder was removed long ago. There is no prior history of chest pain, dyspnea, or systemic hypertension.
The patient does have a history of paroxysmal atrial fibrillation, palpitations, and pulmonary hypertension. She is chronically obese and has hypothyroidism. Surgical history is significant for cholecystectomy, hysterectomy, and left breast lumpectomy with axillary node dissection.
Her job at a local factory, assembling components for pressure washer pumps, requires her to sit for extended periods. She smokes 1.5 packs of cigarettes per day, a habit that began when she was 16. She drinks one or two beers daily and admits she has “many more” on the weekends. She has used marijuana in the recent past but not in the past month. She denies use of any other illicit drugs or homeopathic medications.
Her medication list includes levothyroxine sodium and ibuprofen. She says she’s “supposed to be taking some kind of heart medication” but hasn’t taken it for several months (and cannot remember the name). It was prescribed for her when she was on vacation in the Florida Keys and experienced similar symptoms. She sheepishly admits to trying her husband’s sildenafil, as she’s been told it works for pulmonary hypertension. She is allergic to sulfa and tetracycline.
Review of systems is remarkable for bilateral hip and ankle pain, which she attributes to her weight. She has had no change in bowel or bladder function. The remainder of the review is unremarkable.
Physical exam reveals a weight of 297 lb and height of 5’6”. Vital signs include a blood pressure of 128/88 mm Hg; pulse, 90 beats/min; respiratory rate, 14 breaths/min-1; temperature, 98.2°F; and O2 saturation, 98.2%.
She is morbidly obese and in no distress. Pertinent physical findings include elevated jugular venous return, bilateral rales in both lung bases, a soft, early diastolic murmur best heard at the left lower sternal border, and a regular rate and rhythm. She also has mild tenderness to deep palpation in the right upper abdominal quadrant. Her lower extremities demonstrate 3+ pitting edema to the level of the knees bilaterally. There are no skin lesions, and the neurologic exam is grossly intact.
As part of her workup, you order an ECG, which reveals a ventricular rate of 94 beats/min; PR interval, 130 ms; QRS duration, 76 ms; QT/QTc interval, 394/492 ms; P axis, 50°; R axis, 80°; and T axis, 47°. What is your interpretation?
ANSWER
Pertinent findings on this ECG include normal sinus rhythm, right atrial enlargement, and a prolonged QT interval. Criteria for right atrial enlargement include P waves > 2.5 mm in leads II, III, and aVF and > 1.5 mm in leads V1 and V2. A prolonged QT interval is evidenced by a QTc > 470 ms using Bazett’s formula (QTc = QT divided by the square root of the RR interval).
The patient’s symptoms and ECG finding of right atrial enlargement coincide with pulmonary hypertension and right-sided heart failure. The prolonged QT interval may be due to her history of hypothyroidism; however, this has not been confirmed.
In the past two weeks, a 59-year-old postmenopausal woman has noticed swelling in her legs and a 10-lb weight gain. For the past three days, she has also had a vague, aching pain in the right upper abdominal quadrant, which surprises her, since her gall bladder was removed long ago. There is no prior history of chest pain, dyspnea, or systemic hypertension.
The patient does have a history of paroxysmal atrial fibrillation, palpitations, and pulmonary hypertension. She is chronically obese and has hypothyroidism. Surgical history is significant for cholecystectomy, hysterectomy, and left breast lumpectomy with axillary node dissection.
Her job at a local factory, assembling components for pressure washer pumps, requires her to sit for extended periods. She smokes 1.5 packs of cigarettes per day, a habit that began when she was 16. She drinks one or two beers daily and admits she has “many more” on the weekends. She has used marijuana in the recent past but not in the past month. She denies use of any other illicit drugs or homeopathic medications.
Her medication list includes levothyroxine sodium and ibuprofen. She says she’s “supposed to be taking some kind of heart medication” but hasn’t taken it for several months (and cannot remember the name). It was prescribed for her when she was on vacation in the Florida Keys and experienced similar symptoms. She sheepishly admits to trying her husband’s sildenafil, as she’s been told it works for pulmonary hypertension. She is allergic to sulfa and tetracycline.
Review of systems is remarkable for bilateral hip and ankle pain, which she attributes to her weight. She has had no change in bowel or bladder function. The remainder of the review is unremarkable.
Physical exam reveals a weight of 297 lb and height of 5’6”. Vital signs include a blood pressure of 128/88 mm Hg; pulse, 90 beats/min; respiratory rate, 14 breaths/min-1; temperature, 98.2°F; and O2 saturation, 98.2%.
She is morbidly obese and in no distress. Pertinent physical findings include elevated jugular venous return, bilateral rales in both lung bases, a soft, early diastolic murmur best heard at the left lower sternal border, and a regular rate and rhythm. She also has mild tenderness to deep palpation in the right upper abdominal quadrant. Her lower extremities demonstrate 3+ pitting edema to the level of the knees bilaterally. There are no skin lesions, and the neurologic exam is grossly intact.
As part of her workup, you order an ECG, which reveals a ventricular rate of 94 beats/min; PR interval, 130 ms; QRS duration, 76 ms; QT/QTc interval, 394/492 ms; P axis, 50°; R axis, 80°; and T axis, 47°. What is your interpretation?
ANSWER
Pertinent findings on this ECG include normal sinus rhythm, right atrial enlargement, and a prolonged QT interval. Criteria for right atrial enlargement include P waves > 2.5 mm in leads II, III, and aVF and > 1.5 mm in leads V1 and V2. A prolonged QT interval is evidenced by a QTc > 470 ms using Bazett’s formula (QTc = QT divided by the square root of the RR interval).
The patient’s symptoms and ECG finding of right atrial enlargement coincide with pulmonary hypertension and right-sided heart failure. The prolonged QT interval may be due to her history of hypothyroidism; however, this has not been confirmed.
Those symptoms first appeared two weeks ago. Now, this woman also has abdominal pain. What does an ECG add to the clinical picture?
What Does This Man Need (Besides Milk & Cookies)?
ANSWER
This ECG is representative of sinus rhythm with second-degree atrioventricular block with 2:1 conduction; possible left atrial enlargement; and ST-T wave abnormalities suspicious for lateral ischemia.
Sinus rhythm is evidenced by the P waves that march through at a rate that is consistently double that of the QRS rate (82 beats/min). The PR interval in the conducted beats remains constant, with every other P wave blocked from conducting into the ventricles.
The biphasic P wave seen in lead V1 does not meet criteria for left atrial enlargement (P wave in lead I ≥ 110 ms, terminal negative P wave in lead V1 ≥ 1 mm2) but is suspicious. Finally, ST-T wave elevations in leads V2-V4 are suspicious for ventricular septal ischemia.
The patient underwent placement of a dual-chamber permanent pacemaker. He has done well since.
ANSWER
This ECG is representative of sinus rhythm with second-degree atrioventricular block with 2:1 conduction; possible left atrial enlargement; and ST-T wave abnormalities suspicious for lateral ischemia.
Sinus rhythm is evidenced by the P waves that march through at a rate that is consistently double that of the QRS rate (82 beats/min). The PR interval in the conducted beats remains constant, with every other P wave blocked from conducting into the ventricles.
The biphasic P wave seen in lead V1 does not meet criteria for left atrial enlargement (P wave in lead I ≥ 110 ms, terminal negative P wave in lead V1 ≥ 1 mm2) but is suspicious. Finally, ST-T wave elevations in leads V2-V4 are suspicious for ventricular septal ischemia.
The patient underwent placement of a dual-chamber permanent pacemaker. He has done well since.
ANSWER
This ECG is representative of sinus rhythm with second-degree atrioventricular block with 2:1 conduction; possible left atrial enlargement; and ST-T wave abnormalities suspicious for lateral ischemia.
Sinus rhythm is evidenced by the P waves that march through at a rate that is consistently double that of the QRS rate (82 beats/min). The PR interval in the conducted beats remains constant, with every other P wave blocked from conducting into the ventricles.
The biphasic P wave seen in lead V1 does not meet criteria for left atrial enlargement (P wave in lead I ≥ 110 ms, terminal negative P wave in lead V1 ≥ 1 mm2) but is suspicious. Finally, ST-T wave elevations in leads V2-V4 are suspicious for ventricular septal ischemia.
The patient underwent placement of a dual-chamber permanent pacemaker. He has done well since.
A 74-year-old man has been a resident of a skilled nursing facility for seven years and is well known to the staff. This morning, when the medical assistant performed a routine vital sign check, she noticed the patient’s heart rate was in the 40s. This newly discovered bradycardia, coupled with a four-day history of lethargy, prompts the facility to transfer the patient to your emergency department for evaluation. The patient has a history of hypertension, hypothyroidism, chronic obstructive pulmonary disease, GERD, osteoarthritis, and dementia. Surgical history includes appendectomy, cholecystectomy, and left hip replacement. The patient’s multiple chronic conditions are well managed with medications, including a b-blocker, hydrochlorothiazide, levothyroxine, and an inhaler. He receives protein and vitamin supplements daily and is allergic to penicillin. There is a remote history of smoking (from his youth and tour of duty in the Korean War), although the patient says he hasn’t smoked in 30 years. He has “never touched” alcohol, because his father died of complications from alcoholism at age 45. The patient’s wife died of a stroke 11 years ago. His son (and family) visit him twice weekly, bringing chocolate milk and cookies that the patient anxiously awaits. The review of systems is remarkable for a recent cold (resolved), urinary retention, and loose stools. The patient’s appetite is intact. He also exhibits evidence of short-term memory loss; however, this is sporadic. Vital signs on arrival include a blood pressure of 158/88 mm Hg; pulse, 48 beats/min and regular; respiratory rate, 14 breaths/min; and temperature, 97.6°F. His weight is 174 lb and his height, 69 in. Pertinent findings on the physical exam include mild cataracts bilaterally, a right carotid bruit, no evidence of elevated neck veins, and late expiratory wheezes in both bases. The cardiac exam is remarkable for a regular rhythm with a heart rate of 42 beats/min. There is a grade II/VI early systolic murmur at the left upper sternal border but no radiation, extra heart sounds, or rubs. The abdomen is soft and nontender, with old surgical scars, and the abdominal aorta is easily palpable. The extremities exhibit full range of motion without peripheral edema, and osteoarthritic changes are evident in both hands. An ECG shows a ventricular rate of 43 beats/min; PR interval, 198 ms; QRS duration, 96 ms; QT/QTc interval, 464/392 ms; P axis, 60°; R axis, 4°; and T axis, 107°. What is your interpretation of this ECG?
Woman Awakens With Rapid Heart Rate
ANSWER
The correct interpretation of this ECG is atrial flutter with a 2:1 block. Careful inspection of lead I reveals a P wave at the terminal portion of the QRS complex, in addition to the P wave seen with a consistent PR interval of 150 ms. This results in two P waves for each QRS complex. Given the presence of the flutter waves, an accurate assessment of the ST segment is not possible.
ANSWER
The correct interpretation of this ECG is atrial flutter with a 2:1 block. Careful inspection of lead I reveals a P wave at the terminal portion of the QRS complex, in addition to the P wave seen with a consistent PR interval of 150 ms. This results in two P waves for each QRS complex. Given the presence of the flutter waves, an accurate assessment of the ST segment is not possible.
ANSWER
The correct interpretation of this ECG is atrial flutter with a 2:1 block. Careful inspection of lead I reveals a P wave at the terminal portion of the QRS complex, in addition to the P wave seen with a consistent PR interval of 150 ms. This results in two P waves for each QRS complex. Given the presence of the flutter waves, an accurate assessment of the ST segment is not possible.
Three nights ago, a 44-year-old woman awoke with a regular, rapid heart rate that lasted about 15 minutes before abruptly terminating. The next morning, at the hospital where she works as an emergency department (ED) nurse, she had a colleague perform an undocumented ECG that, by the patient’s account, was normal. Early this morning, she was again awakened by a similar regular but rapid heart rate. Not wanting anyone at her facility to know about the problem, she presents to your ED instead. She denies chest pain but admits that she is slightly short of breath, adding that her symptoms remind her of how she feels when finishing a 10K run. The patient has been in excellent health with no underlying medical problems and no prior cardiac history. She is an avid runner, averaging three miles a day, and does not smoke. She does report drinking two or three glasses of wine in the evenings and admits she likes to party on the weekends, frequently consuming three or four margaritas with her coworkers on Saturday nights. She experimented with cannabis in college but hasn’t used illicit or recreational drugs since graduating. The patient is divorced, has a steady boyfriend, and has no children or siblings. Her parents are alive and well, with no history of arrhythmias, cardiovascular disease, or diabetes. She has no known drug allergies. Her medications include an oral contraceptive and occasional ibuprofen for soreness following exercise. The review of systems is remarkable for menses, which began yesterday. She denies that she is pregnant. Her vision is corrected with contact lenses. Physical examination reveals a thin, athletic-appearing woman who seems anxious. Her height is 67 in and her weight, 132 lb. Vital signs include a blood pressure of 118/68 mm Hg; pulse, 150 beats/min; respiratory rate, 14 breaths/min-1; and temperature, 37.8°C. The HEENT exam is normal with the presence of contact lenses. There is no thyromegaly. The lungs are clear in all fields. Her cardiac exam reveals a regular, rapid rate of 150 beats/min, without murmurs, rubs, or extra heart sounds. The abdomen is soft and nontender without palpable masses. The peripheral pulses are strong and equal bilaterally. There is no peripheral edema. The neurologic exam is intact. Laboratory tests, including a complete blood count, thyroid panel, and chemistry panel, are performed. All values are within normal limits. An ECG reveals a ventricular rate of 149 beats/min; PR interval, 150 ms; QRS interval, 102 ms; QT/QTc interval, 270/425 ms; P axis, 103°; R axis, 78°; and T axis, –18°. What is your interpretation of this ECG?
Man With Diverticulitis Undergoes Precolonoscopy Evaluation
ANSWER
This ECG shows probable ectopic rhythm with second-degree atrioventricular (AV) block and a nonspecific intraventricular conduction block.
The P-wave morphology is unusual; rather than being upright and positive in leads II and aVF, the P waves are biphasic and prolonged, suggesting they originate from an atrial source other than the sinus node.
The rhythm strip of lead I in this ECG isn’t of much help in determining the atrial rhythm, as the P waves are small. However, if you look at the strip beginning with either lead II or III and keep in mind that the strip is continuous even though the leads change (eg, lead III becomes lead aVF which becomes V3, etc), you can see an atrial complex immediately following the T wave that is very similar to the P wave prior to the QRS complex. The rate of the P waves is 84 beats/min, which is twice that of the QRS complex (42 beats/min) and therefore consistent with a 2:1 heart block.
A nonspecific AV conduction block is evidenced by a QRS duration > 120 ms that does not have the appearance of a right or left bundle branch block.
Finally, while the QT interval of 514 ms is worrisome for long QT interval, it is normal when corrected for rate.
ANSWER
This ECG shows probable ectopic rhythm with second-degree atrioventricular (AV) block and a nonspecific intraventricular conduction block.
The P-wave morphology is unusual; rather than being upright and positive in leads II and aVF, the P waves are biphasic and prolonged, suggesting they originate from an atrial source other than the sinus node.
The rhythm strip of lead I in this ECG isn’t of much help in determining the atrial rhythm, as the P waves are small. However, if you look at the strip beginning with either lead II or III and keep in mind that the strip is continuous even though the leads change (eg, lead III becomes lead aVF which becomes V3, etc), you can see an atrial complex immediately following the T wave that is very similar to the P wave prior to the QRS complex. The rate of the P waves is 84 beats/min, which is twice that of the QRS complex (42 beats/min) and therefore consistent with a 2:1 heart block.
A nonspecific AV conduction block is evidenced by a QRS duration > 120 ms that does not have the appearance of a right or left bundle branch block.
Finally, while the QT interval of 514 ms is worrisome for long QT interval, it is normal when corrected for rate.
ANSWER
This ECG shows probable ectopic rhythm with second-degree atrioventricular (AV) block and a nonspecific intraventricular conduction block.
The P-wave morphology is unusual; rather than being upright and positive in leads II and aVF, the P waves are biphasic and prolonged, suggesting they originate from an atrial source other than the sinus node.
The rhythm strip of lead I in this ECG isn’t of much help in determining the atrial rhythm, as the P waves are small. However, if you look at the strip beginning with either lead II or III and keep in mind that the strip is continuous even though the leads change (eg, lead III becomes lead aVF which becomes V3, etc), you can see an atrial complex immediately following the T wave that is very similar to the P wave prior to the QRS complex. The rate of the P waves is 84 beats/min, which is twice that of the QRS complex (42 beats/min) and therefore consistent with a 2:1 heart block.
A nonspecific AV conduction block is evidenced by a QRS duration > 120 ms that does not have the appearance of a right or left bundle branch block.
Finally, while the QT interval of 514 ms is worrisome for long QT interval, it is normal when corrected for rate.
A 74-year-old man with recurring episodes of melena presents for a preoperative evaluation prior to colonoscopy. He has had three such procedures in the past five years, all of which indicated diverticulitis. The current episode began about a month ago, but the patient delayed seeking care until last week due to work obligations. The patient reports feeling more lethargic and becoming more easily tired than he has with previous episodes, which concerns him. He doesn’t think he has lost more blood than before but admits he’s been “too busy” to notice. He denies chest pain, shortness of breath, palpitations, peripheral extremity swelling, or recent weight change (gain or loss). He has not experienced loss of appetite or abdominal pain. Medical history is remarkable for hypertension, cholecystitis, and diverticulitis. There is no history of coronary artery disease, diabetes, or chronic obstructive pulmonary disease. Surgical history is remarkable for cholecystectomy and surgical repair of a high fracture of the left ankle. The patient owns a 475-acre farm, where he has lived his entire life. He is a widower who relies on his four sons to help with chores, although he insists on driving the combine himself during harvest (which is why he delayed seeking care this time). He does not smoke or drink. His current medications include hydrochlorothiazide and naproxen as needed for musculoskeletal discomfort. The review of systems is remarkable for fatigue and “the usual aches and pains of working on a farm.” The remainder of the review is noncontributory. The physical exam reveals a thin, weather-worn male in no distress. His height is 76 in and his weight, 172 lb. Both are unchanged from his previous clinic visit (six months ago). Vital signs include a blood pressure of 138/78 mm Hg; pulse, 46 beats/min; O2 saturation, 96%; and temperature, 98.2°F. Pertinent findings include normal breath sounds, a regular (albeit slow at 46 beats/min) rhythm, an early grade II/VI systolic murmur heard at the left upper sternal border, and a soft, nontender abdomen. There is no peripheral edema and no femoral or carotid bruits. The neurologic exam is intact. While the patient is undergoing preoperative laboratory tests and ECG, you review his medical record. Of note, the bradycardia found during today’s physical was not present six months ago. Laboratory data include a normal chemistry panel and a hematocrit of 38%. The ECG reveals a ventricular rate of 42 beats/min; PR interval, not reported; QRS duration, 130 ms; QT/QTc interval, 514/429 ms; P axis, 83°; R axis, 84°; and T axis, –43°. What is your interpretation of this ECG?
Fatal Family History Worries Young Man
ANSWER
The ECG shows normal sinus rhythm and left ventricular hypertrophy (LVH). LVH is indicated by high voltages in limb leads I and III (sum of R and S waves in leads I and III ≥ 25 mm) or in precordial leads V1, V5, and/or V6 (sum of V1 and either V5 or V6 ≥ 35 mm).
Subsequent work-up, including echocardiography and genetic testing, revealed a familial LVH.
ANSWER
The ECG shows normal sinus rhythm and left ventricular hypertrophy (LVH). LVH is indicated by high voltages in limb leads I and III (sum of R and S waves in leads I and III ≥ 25 mm) or in precordial leads V1, V5, and/or V6 (sum of V1 and either V5 or V6 ≥ 35 mm).
Subsequent work-up, including echocardiography and genetic testing, revealed a familial LVH.
ANSWER
The ECG shows normal sinus rhythm and left ventricular hypertrophy (LVH). LVH is indicated by high voltages in limb leads I and III (sum of R and S waves in leads I and III ≥ 25 mm) or in precordial leads V1, V5, and/or V6 (sum of V1 and either V5 or V6 ≥ 35 mm).
Subsequent work-up, including echocardiography and genetic testing, revealed a familial LVH.
A college student, 19, presents with increasing palpitations. Six months ago, when they began, they were rare and intermittent; now they occur daily, primarily at night. He has just received an athletic scholarship and worries that the palpitations may affect his ability to play. Furthermore, his older brother died of sudden cardiac death in high school, while playing football, and the patient is afraid this may happen to him too. He is in otherwise excellent health and has never been hospitalized. He takes no medications but has smoked marijuana a couple of times. He has not used performance enhancing drugs or homeopathic medications. A careful review of his family history reveals that two uncles, a brother, and a cousin died of sudden cardiac death. Their ages at the time of death were 42, 51, 17, and 54, respectively. Review of systems is unremarkable. Vital signs include a blood pressure of 108/62 mm Hg; pulse, 60 beats/min; and respiratory rate, 14 breaths/min-1. His weight is 179 lb and his height, 78 in. The physical exam reveals a tall, thin, well-developed young male in no distress. A comprehensive examination reveals no adverse findings. There are no palpitations heard or felt. Despite the lack of unusual physical findings, the patient’s family history concerns you. You decide to order an ECG and an echocardiogram. The ECG shows a ventricular rate of 61 beats/min; PR interval, 120 ms; QRS duration, 108 ms; QT/QTc interval, 430/432 ms; P axis, –25°; R axis, –14°; and T axis, 12°. What is your interpretation of this ECG—and is further work-up indicated?
