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ANSWER
There are three significant findings on this ECG. First, the rhythm shows complete heart block. The ventricular rate is 56 beats/min, and the QRS complex is narrow, resulting in a junctional rhythm. The atrial rate is 98 beats/min (consistent with a sinus rhythm), and there is no relationship of the P waves to the QRS complexes.
The second finding is a rightward axis deviation. Note that the QRS complexes are negative in lead I and positive in lead aVF. To meet criteria for a right-axis deviation, the QRS complex must also be positive in lead aVR. In this case, the QRS complex appears to be isoelectric in aVR, so we call the axis rightward.
The presence of rightward axis deviation is a result of the third finding, an anterior MI. This is due to the LAD artery occlusion discovered at catheterization. It is evident on the ECG by the absence of significant R waves in leads V1 through V4.
Given the need for a β-blocker with titration of dose, the patient underwent implantation of a permanent pacemaker system.
ANSWER
There are three significant findings on this ECG. First, the rhythm shows complete heart block. The ventricular rate is 56 beats/min, and the QRS complex is narrow, resulting in a junctional rhythm. The atrial rate is 98 beats/min (consistent with a sinus rhythm), and there is no relationship of the P waves to the QRS complexes.
The second finding is a rightward axis deviation. Note that the QRS complexes are negative in lead I and positive in lead aVF. To meet criteria for a right-axis deviation, the QRS complex must also be positive in lead aVR. In this case, the QRS complex appears to be isoelectric in aVR, so we call the axis rightward.
The presence of rightward axis deviation is a result of the third finding, an anterior MI. This is due to the LAD artery occlusion discovered at catheterization. It is evident on the ECG by the absence of significant R waves in leads V1 through V4.
Given the need for a β-blocker with titration of dose, the patient underwent implantation of a permanent pacemaker system.
ANSWER
There are three significant findings on this ECG. First, the rhythm shows complete heart block. The ventricular rate is 56 beats/min, and the QRS complex is narrow, resulting in a junctional rhythm. The atrial rate is 98 beats/min (consistent with a sinus rhythm), and there is no relationship of the P waves to the QRS complexes.
The second finding is a rightward axis deviation. Note that the QRS complexes are negative in lead I and positive in lead aVF. To meet criteria for a right-axis deviation, the QRS complex must also be positive in lead aVR. In this case, the QRS complex appears to be isoelectric in aVR, so we call the axis rightward.
The presence of rightward axis deviation is a result of the third finding, an anterior MI. This is due to the LAD artery occlusion discovered at catheterization. It is evident on the ECG by the absence of significant R waves in leads V1 through V4.
Given the need for a β-blocker with titration of dose, the patient underwent implantation of a permanent pacemaker system.
Three days ago, a 62-year-old man was admitted with chest pain and an MI (confirmed by cardiac enzymes). The chest pain started while he was working on his farm, but he did not seek immediate help because he assumed it was heartburn and he had chores to finish. When the pain did not resolve overnight, he finally presented to the emergency department. Cardiac catheterization revealed an occluded left anterior descending (LAD) artery distal to the first diagonal branch and diffuse disease in the circumflex and right coronary arteries. An echocardiogram showed diffuse left ventricular hypokinesis and no evidence of valvular disease. His left ventricular ejection fraction was estimated to be 48%. Medical history is remarkable for hypertension and gout. Surgical history is remarkable for an appendectomy at age 7 and surgical repair of a fractured tibia from a high school football injury. Family history is positive for coronary artery disease; both parents died at young ages (father at 60, mother at 65) of MI, and his older brother had an MI at age 50 (but is currently doing well). The patient owns a 475-acre farm on which he grows corn and soybeans. He also tends to 23 cows and has a large chicken coop. There are five workers to help, but he states that he does most of the work himself. He is divorced and lives alone with five dogs, whom he refers to as his “kids.” He does not smoke, but he has one beer and one shot of bourbon with dinner each night. His only medication at the time of admission was ibuprofen. He had been prescribed lisinopril in the past but hadn’t taken it in six months because “it’s too far a drive to get it refilled.” He has no known drug allergies. Following admission, he was started on a β-blocker (metoprolol), aspirin, atorvastatin, and lisinopril. During rounds, you notice that his hypertension is well controlled. His blood pressure is 118/80 mm Hg, compared to 180/92 mm Hg on admission. He is comfortable and wants to know when he can go home. As you contemplate discharge, a technician hands you the patient’s daily ECG tracing. It shows a ventricular rate of 56 beats/min; QRS duration, 106 ms; QT/QTc interval, 400/386 ms; P axis, 36°; R axis, 120°; and T axis, 7°. What is your interpretation of this ECG?
