ECG Review: And If the Patient Had Chest Pain?
ECG Review
And If the Patient Had 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.
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Scenario
The ECG above was obtained from a 62-year-old man with hypertension who was being seen in the office. How would you interpret this tracing if he had told you of some chest discomfort that he felt for the first time earlier that morning?
Interpretation
The rhythm is sinus bradycardia at a rate just under 60/min. All intervals are normal. The axis is at 0°. The P wave in lead II is tall, peaked, and pointed, satisfying criteria for right atrial abnormality. Left atrial abnormality is probably also present, given the fairly deep negative component to the P wave in lead V1. There is left ventricular hypertrophy (LVH) and "strain" with voltage criteria satisfied by deepest S in V1,V2 plus tallest R wave in V5,V6 exceeding 35 mm. ST-T wave abnormalities consistent with repolarization changes of LVH are seen in virtually all of the lateral leads. A narrow (probably septal) q wave is seen in lead aVL. A small r wave develops by lead V2 (as it should), though transition is slightly delayed (occurring between V4 to V5). However, the principal finding of concern on this tracing is the slight but definite J point ST segment depression that is seen in the lateral precordial leads (leads V4 through V6). While LV "strain" as is seen in a hypertensive patient with LVH typically produces a picture of ST segment asymmetric sagging (seen here in leads I and aVL) it usually does not significantly depress the J point into a coved and depressed ST segment (V5,V6), and it usually does not produce the straight (albeit slight) ST segment depression seen in lead V4. Although these changes are admittedly subtle and could simply reflect this patient's underlying hypertensive heart disease and/or medication effect if new, they could also reflect acute ischemia. Remember that the ECG is simply the net effect of the sum of all acting forces, and that underlying hypertensive ST-T wave repolarization changes may limit the expression of ischemic ST-T wave changes to relatively subtle ST depression. Whether work-up and management of this patient's new chest discomfort could proceed as an outpatient would depend on the clinical history.
The ECG above was obtained from a 62-year-old man with hypertension who was being seen in the office. How would you interpret this tracing if he had told you of some chest discomfort that he felt for the first time earlier that morning?Subscribe Now for Access
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