ECG Review

Anxiety or Atrial Fibrillation in an Older Woman?

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.


Figure — 12-lead ECG from an older woman with anxiety and “heart sensations.” Is she in atrial fibrillation?

Scenario: The 12-lead ECG shown above was obtained from an older woman who was extremely anxious about her home situation. She felt some “heart sensations.” Is she in atrial fibrillation?

Interpretation: At first glance, the patient appears to be in atrial fibrillation. The rhythm is irregular, and normal upright P waves are not seen preceding each QRS complex in lead II. That said — artifact is present, and there is some baseline wander in lead II. The rhythm is fairly regular in other leads and careful inspection before the QRS complex in lead aVF and in lead V4 does suggest the presence of an upright P wave with fixed PR interval. Thus, although impossible to know for sure, we strongly suspect an underlying sinus mechanism with frequent premature atrial contractions (PACs) as the rhythm. The occurrence of frequent PACs is clearly one cause of heart sensations.

Continuing with our systematic interpretation — intervals and axis are normal, and there is no chamber enlargement. However, assessment of Q-R-S-T changes is of definite concern. Specifically, Q waves are present in the inferior and lateral precordial leads. The Q waves in leads III and aVF are relatively deep and wide. The Q wave in lead V6 is wider than anticipated for a normal septal q wave. Transition occurs at a normal point (between leads V2-to-V3), however, there is a fairly abrupt increase in R wave amplitude in lead V3.

The most concerning finding is ST segment elevation in each of the inferior leads. Although the amount of ST elevation varies from beat-to-beat in simultaneously recorded leads II and III (due to baseline wander), the finding of coved ST elevation above the PR segment baseline is unmistakable. There is also a hint of ST elevation in lead V6. Support that these findings are truly acute is forthcoming from the presence of reciprocal ST segment depression in multiple leads (leads I, aVL, V2, V3, V4). An additional subtle reciprocal change is disproportionate peaking of the T wave in leads V3 and V4. Taken together, these findings suggest acute infero-lateral-postero STEMI (ST segment elevation myocardial infarction) as a more important contributing cause to this older woman’s “heart sensations.”