Man in Distress With Lower Extremity Pain

A 53-year-old white man is referred for an adenosine myocardial perfusion scan stress test prior to left femoral popliteal bypass graft surgery. An ECG obtained one month ago was interpreted as normal. A transthoracic echocardiogram at that time revealed a normal left ventricular ejection fraction (> 55%) with normal wall motion and no pathologic valvular heart disease. The patient is in distress due to left lower extremity vascular ischemic rest pain. He admits that earlier this morning, he was slightly dyspneic. However, he denies chest pain. He admits to not taking aspirin (162 mg Q day) as prescribed for the past two days. He also reports an 88–pack-year smoking history. Pulmonary function tests support mild obstructive emphysematous changes. The patient is 68” tall and weighs 128 lb (BMI, 19.5). His vital signs include: a blood pressure of 128/82 mm Hg; ventricular rate, 94 beats/min; respiratory rate, 20 breaths/min; and O2 saturation, 90% on room air. He is afebrile. Pertinent physical findings include no jugular venous distention and no bilateral carotid, femoral, or abdominal bruits. The neurologic exam is unremarkable. The cardiac exam reveals a regular rate and rhythm with an S3 gallop; there is no S4, murmur, or click. There is no peripheral edema. Femoral pulses are +1. Pedal pulses are absent. Stat cardiac enzymes reveal a normal CK-MB (3.3 U/L) and an elevated troponin T level (0.117 μg/L; normal, 0.00 to 0.03). The complete blood count, prothrombin time/partial thromboplastin time/INR tests, and other chemistry panels all yield normal results. This patient’s ECG shows the following: a ventricular rate of 90 beats/min; PR interval, 135 ms; QRS duration, 96 ms; QT/QTc interval, 394/476 ms; P axis, 67°; R axis, 68°; and T axis, 172°. What is your interpretation of this ECG?