ECG of the Week – 17th June 2020 – Interpretation

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The following ECG has been taken from an 88 year old man who has presented with intermittent chest pain.

He has no background history of MI but has had a normal angiogram in the last 3 years after investigation for ventricular ectopics. Whilst symptomatic he feels mildly short of breath but has reported no pre-syncope. His medications are Amlodipine and Rabeprazole. On examination he is pain free and has a HR of 72, BP 156/57, RR20, Sats 94%, afebrile and normoglycaemic. He has an irregular heart rate and a soft ejection systolic murmur. His first ECG showed only 1st degree heart block but you have been asked to sign a second ECG taken with his serial troponin. Your handover is that he may go home if that troponin is negative

Interpretation

  • Rate: 42
  • Rhythm: Ventriculophasic sinus arrhythmia
  • Axis: Normal (0 to -30)
  • Morphology: QRS fragmentation in V2 RsrS pattern, subtle STD aVL and V5-6, subtle STE aVR
  • Intervals: Progressive prolongation of PR interval with final failure of QRS capture (seen after 2nd and 8th p wave), shortened R-R intervals in each beat of the cycle (most notable comparison between complex 3-4 and 4-5)
  • Summary: 2nd degree heart block: Mobitz Type 1

A word on Ventriculophasic sinus arrhythmia:

  • associated with 2nd and 3rd degree heart block
  • irregular p waves seen
  • shorter p-p interval seen when p waves assoc with QRS complexes vs longer p-p interval if no QRS associated
  • can also be seen as paradoxical ventriculophasic sinus arrhythmia where p-p intervals are reversed to the above (see citation below)

Management:

  • Given that the patient shows no signs of shock, syncope,  gross myocardial ischaemia (see also recent angio below) or cardiac failure his current symptoms are unlikely to be related to these ECG findings and his bradycardia does not warrant immediate treatment.
  • However a rate of around 40 in an elderly gentleman warrants an admission for telemetry.
  • Clinical closure – he was admitted for telemetry, had an Echo that showed an EF 55%, mild aortic and tricuspid regurgitation and a moderate dilated LA. He was discharged after 2 days and the cardiology team recommended not for B blockers or cardio selective CCBs in his ongoing care. He had recently had a angiogram with normal coronary vessels.

Further Reading – Textbook:

Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.

Further reading – Online: