ECG Challenge Response ECG Response: October 7, 2014 ECG Challenge: A 56-year-old man with a history of prostatic hypertrophy presents to the emergency department with a concern about the inability to void. He is observed to have urinary retention and a Foley catheter is inserted. He is admitted to the hospital and placed on telemetry. An ECG is obtained (ECG A). Several hours after admission he spikes a temperature to 102°F and is felt to have a urinary tract infection and antibiotics are begun. The nurse notes a change in his QRS complexes on telemetry and an ECG is repeated (ECG B).
ECG A shows a regular rhythm with a rate of 64 bpm. There is a P wave before each QRS complex (+) with a stable PR interval (0.18 second). The P waves are positive in leads I, II, aVF, and V4 through V6. Hence, this is a normal sinus rhythm. The QRS complexes are narrow (0.08 second) and have a physiological left axis between 0° and –30° (positive
QRS complex in leads I and II and negative in aVF). The morphology is normal except for a positive waveform noted at the end of the QRS complex in lead V1 (↓). This is suggestive of either early repolarization or possibly an R′, consistent with an intraventricular conduction delay to the right ventricle. In addition, there is J-point elevation in lead V2 (^) that is suggestive of early repolarization. There is early transition with a tall R wave in lead V2 (←); this is termed counterclockwise rotation of the electric axis in the horizontal plane. This is established by imagining the heart as if viewed under the diaphragm. With early transition, the left ventricular forces develop early and appear in the right precordial leads. The QT/QTc intervals are normal (400/415 ms). ECG B was obtained several hours later when the patient was febrile. There is a regular rhythm at a rate of 100 bpm. There is a P wave before each QRS complex (+) with a stable PR interval (0.16 second). The P waves are positive in leads I, II, aVF, and V4 through V5. Thus, this is a sinus tachycardia. The QRS complex duration and axis are the same as seen in ECG A. The QT/QTc intervals are the same (320/415 ms). Although the QRS complex morphology is similar to the QRS complexes in ECG A, there are changes in leads V1 through V2. Lead V1 shows marked J-point and ST-segment elevation (v). This has been termed a pseudo right bundle-branch block, and it may also be confused with ST-segment elevation because of an acute myocardial infarction. However, the J point is elevated and there is a slowly downsloping ST segment that merges with an inverted T wave. In V2, there is J-point and ST-segment elevation (↓). The ST segment is notched. This has been called saddle back ST elevation. The abnormalities seen in leads V1 through V2 are typical for a Brugada pattern (type 2). Although ECG A has an abnormality noted in lead V1 through V2, this is not a typical Brugada pattern, although it is suggestive. However, with an elevated temperature, a typical Brugada pattern is exposed. Please go to the journal’s Facebook page for more ECG Challenges: http://goo.gl/cm4K7. Challenges are posted on Tuesdays and Responses on Wednesdays.
Correspondence to Philip J. Podrid, MD, West Roxbury VA Hospital, Section of Cardiology, 1400 VFW Pkwy, West Roxbury, MA 02132. E-mail [email protected] (Circulation. 2014;130:1299.) © 2014 American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org
DOI: 10.1161/CIRCULATIONAHA.114.012964
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ECG Response: October 7, 2014 Circulation. 2014;130:1299 doi: 10.1161/CIRCULATIONAHA.114.012964 Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2014 American Heart Association, Inc. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circ.ahajournals.org/content/130/15/1299
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Circulation can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Circulation is online at: http://circ.ahajournals.org//subscriptions/
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ECG A shows a regular rhythm with a rate of 64 bpm. There is a P wave before each QRS complex (+) with a stable PR interval (0.18 second). The P waves are positive in leads I, II, aVF, and V4 through V6. Hence, this is a normal sinus rhythm. The QRS complexes are narrow (0.08 second) and have a physiological left axis between 0° and –30° (positive
QRS complex in leads I and II and negative in aVF). The morphology is normal except for a positive waveform noted at the end of the QRS complex in lead V1 (↓). This is suggestive of either early repolarization or possibly an R′, consistent with an intraventricular conduction delay to the right ventricle. In addition, there is J-point elevation in lead V2 (^) that is suggestive of early repolarization. There is early transition with a tall R wave in lead V2 (←); this is termed counterclockwise rotation of the electric axis in the horizontal plane. This is established by imagining the heart as if viewed under the diaphragm. With early transition, the left ventricular forces develop early and appear in the right precordial leads. The QT/QTc intervals are normal (400/415 ms). ECG B was obtained several hours later when the patient was febrile. There is a regular rhythm at a rate of 100 bpm. There is a P wave before each QRS complex (+) with a stable PR interval (0.16 second). The P waves are positive in leads I, II, aVF, and V4 through V5. Thus, this is a sinus tachycardia. The QRS complex duration and axis are the same as seen in ECG A. The QT/QTc intervals are the same (320/415 ms). Although the QRS complex morphology is similar to the QRS complexes in ECG A, there are changes in leads V1 through V2. Lead V1 shows marked J-point and ST-segment elevation (v). This has been termed a pseudo right bundle-branch block, and it may also be confused with ST-segment elevation because of an acute myocardial infarction. However, the J point is elevated and there is a slowly downsloping ST segment that merges with an inverted T wave. In V2, there is J-point and ST-segment elevation (↓). The ST segment is notched. This has been called saddle back ST elevation. The abnormalities seen in leads V1 through V2 are typical for a Brugada pattern (type 2). Although ECG A has an abnormality noted in lead V1 through V2, this is not a typical Brugada pattern, although it is suggestive. However, with an elevated temperature, a typical Brugada pattern is exposed. Please go to the journal’s Facebook page for more ECG Challenges: http://goo.gl/cm4K7. Challenges are posted on Tuesdays and Responses on Wednesdays.
Correspondence to Philip J. Podrid, MD, West Roxbury VA Hospital, Section of Cardiology, 1400 VFW Pkwy, West Roxbury, MA 02132. E-mail [email protected] (Circulation. 2014;130:1299.) © 2014 American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org
DOI: 10.1161/CIRCULATIONAHA.114.012964
Downloaded from http://circ.ahajournals.org/ by guest on March 8, 2015 1299
ECG Response: October 7, 2014 Circulation. 2014;130:1299 doi: 10.1161/CIRCULATIONAHA.114.012964 Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2014 American Heart Association, Inc. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circ.ahajournals.org/content/130/15/1299
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Circulation can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Circulation is online at: http://circ.ahajournals.org//subscriptions/
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