The ECG below has been taken from an 89 year old gentleman who has just transferred from the SJA stretcher to an ED bed. He has a history of prostate cancer, IHD and Aortic Stenosis and had an episode of central chest pain with an associated collapse but is now pain free.
Interpretation
- Rate: 108
- Rhythm: sinus rhythm
- Axis: -30 to -90 = LAD
- Morphology: Markedly abnormal. Bifid p waves with terminal negative p in V1. RBBB. Global ischaemia (STD with sparing in leads aVL/V2, 1mm STE aVR, mild STE V1, biphasic T waves V4-6) Prominent R wave AVR
- Intervals: PR 160 QRS 120-140
- Summary: Sinus tachycardia, LAA + RBBB + LVH + LAD Global ischaemia – see discussion below.
Differential
- PE
- ACS – demand ischaemia in the context of aortic stenosis vs acute occlusion
- Electrolytes
- Drugs eg digoxin
Management and Investigations
- Investigations: Old ECG, Telemetry, Spot trop (result l64), CXR
- Resus: none required on ABC assessment
- Supportive Care: none needed
- Specific Treatment: Analgesia – pain free, Oxygen – aim Sats > 92% (or 88-92% if history of COPD), Aspirin 300mg,
- Disposition: Cardiology admission
Clinical Closure:
- This man had had a 3 week history of crescendo angina.
- Previous Angiograms had resulted in angioplasty of LAD / Lcx and RCA
- He had a trop rise of 164 to 189 and was transferred to his private cardiologist for a repeat angio (sadly these results are not available to me)
Further Reading – Textbook:
Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.