An Asymptomatic 87-year-old Woman
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.
Scenario: The ECG above was obtained from an 87-year-old woman in for her first doctor visit in several years. She reports no recent symptoms. She is on no cardioactive medications. What are your concerns?
Interpretation: Although the P wave in lead II is small in amplitude, it is upright. This suggests that the rhythm is sinus. The rate is slow and somewhat irregular. Thus, the rhythm is sinus bradycardia and arrhythmia, with a heart rate in the 40s. The PR interval is normal, but the QRS is widened in the form of complete right bundle branch block (RBBB). There is no significant axis deviation, and no sign of chamber enlargement. The most remarkable finding on this tracing is ST segment coving with deep, symmetric T wave inversion in the infero-lateral leads. Three other findings of note are: 1) a QR pattern in lead V1 (instead of the usual rSR' expected with RBBB); 2) a deep (albeit slender) Q wave in lead aVL; and 3) the upright T wave in lead V1.
Normally with left or right bundle branch block, the ST-T wave should be oppositely directed to the last QRS deflection in the 3 key leads (I, V1, V6). This is not the case here. Instead of a negative ST-T wave in V1 and an upright T wave in leads I and V6, we see the opposite. This reflects a "primary" ST-T wave change, and suggests ischemia. The fact that there is a QR pattern in lead V1 and a fairly deep Q in aVL suggest that there has been infarction at some point (which perhaps caused the RBBB).
Despite the above abnormalities, this 87-year-old woman was asymptomatic. Sick sinus syndrome with underlying coronary disease is likely (perhaps with a recent silent event), though impossible to determine in the absence of prior tracings and more history. Careful follow-up would be prudent, and she may need a pacemaker.