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A Woman with Heart Problems
By Ken Grauer, MD, Professor Emeritus in Family Medicine, College of Medicine, University of Florida. Dr. Grauer is the sole proprietor of KG-EKG Press, and publisher of an ECG pocket brain book.
Scenario: The ECG above was obtained in the office from a 47-year-old woman who said she had "heart problems" that resulted in hospitalization the month before. She has had no symptoms over the past few weeks. How would you interpret her ECG? What kind of heart problems might she have had?
Interpretation: This is an extremely interesting tracing. The rhythm is slow and regular, at a rate of about 60/minute. Although the rhythm appears to be sinus (with upright P waves in lead II) a tiny, vertical spike precedes the P wave in this lead as well as in several other leads (best seen in leads II, III, and aVF). The patient has a DDD pacemaker, and is being atrial paced. The QRS is obviously wide, but not preceded by any pacing spike. Thus, there is atrial pacing at 60/minute with preservation of normal AV conduction. QRS morphology is consistent with complete right bundle branch block (RBBB) with an rSR' complex in lead V1 and wide terminal S waves in leads I, V6. There are deeper-than-expected Q waves in leads I and, especially aVL, suggesting possible prior lateral infarction. Support for this possibility derives from the ST segment coving and shallow T wave inversion in lead aVL. ST segment coving and symmetric T wave inversion is also seen in lead I and across the precordial leads. Although normally there is ST-T wave depression in anterior precordial leads with RBBB it should not be nearly as diffuse as is seen here.
We suspect this patient's heart problems are related to one or more episodes of marked bradycardia, necessitating placement of a permanent pacemaker. The fact that she is set to atrial pacing suggests that there was no significant AV block. Her RBBB, lateral Q waves, and diffuse ST-T wave changes probably reflect ischemia and/or recent infarction.