This week’s ECG is from a 72yr old with known atrial fibrillation and a PPM in situ. He presents with several days of atypical chest pain. Medications include metoprolol, frusemide, and low molecular weight heparin (intolerant of warfarin).
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- Mean ventricular rate ~78 bpm
- Irregularly irregular native ventricular activity
- Nil clear p waves
- Irregularity to baseline in leads II, III, V1-2
- Single ventricular paced complex
- Complex #6
Intervals Native Complexes:
- QRS – Normal (~70ms)
- QT – 380ms
- QRS – Prolonged (120ms)
- QT – 420ms
- ST Elevation aVR
- ST Depression leads I, II, V4-6
- Discordant ST segment change in paced complex
- Paced complex occurs 1000ms following R wave peak of preceding complex
- T wave inversion leads II, III, aVF, aVL, V4-5
- Undulating baseline in inferior and precordial leads
- ? flutter vs U waves vs artifact
- Rate controlled atrial fibrillation
- Single paced complex
- ST / T wave changes non-diagnostic, consider
- Drug effects esp. digoxin
- Electrolyte abnormality
- Doesn’t quite meet voltage criteria for LVH
What happened ?
Serial ECG’s showed no dynamic changes, and serial troponins were negative.
Medication review confirmed the patient was not on digoxin.
He was discharged from the Emergency Department with planned out-patient cardiology follow-up with his usual specialist.
Sorry for the anti-climactic ending but the truth is that this is what happens to a significant portion of the patients we see with chest pain, non-dynamic longstanding ECG abnormalities, and negative cardiac biomarkers.
References / Further Reading
Life in the Fast Lane
- Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.