ECG Review

An Octogenarian in Heart Failure

Figure. 12-lead ECG obtained from an 81-year old woman with new onset heart failure, but no chest pain.

By Ken Grauer, MD, Professor, Department of Community Health and Family Medicine, University of Florida Dr. Grauer is the sole proprietor of KG-EKG Press, and publisher of an ECG pocket brain book.

Clinical Scenario: The ECG in the Figure was obtained from a 81-year old woman who presented with new-onset heart failure. She described shortness of breath, but no chest pain. What may have caused her heart failure?

Interpretation/Answer: The underlying rhythm is sinus at a rate of about 90/minute. There is one PAC (premature atrial contraction), which is the fourth beat. The PR, QRS and QT intervals are normal. The axis is close to 0°. There is no ECG evidence of chamber enlargement. R wave progression is slightly delayed (with transition occurring between leads V4 to V5), and small S waves persist in leads V4 through V6. For the most part, ST-T waves show a flattened appearance that is non-specific. The most interesting part of this tracing (given the clinical context) is seen in the high lateral leads (leads I and aVL). In addition to small q waves, there is subtle (but real!) ST segment elevation. This is clearly the case for all four beats (including the PAC) in lead I, and admittedly less certain (due to beat-to-beat variation) in lead aVL. This patient had positive troponins that confirmed her acute high lateral myocardial infarction.