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There are three findings on this ECG: unusual P waves consistent with a possible ectopic atrial rhythm, a prolonged QT interval, and T-wave abnormalities in the lateral leads.
Note that the P waves are negative in leads I and II, as well as in all chest leads. This is highly suggestive of an ectopic atrial rhythm originating low in the atria, conducting retrograde into the atria, and overriding the sinoatrial node. Limb lead reversal would result in negative P waves in lead I, but not in other leads.
A prolonged QT interval is determined by consulting any of the standard charts that correlate maximum heart rates with QT intervals and gender. In men, the QT interval is considered “prolonged” when it exceeds 440 ms, unless the heart rate is extremely slow.
Finally, T-wave inversions are present in the lateral leads (V5, V6). Although this may be an indication of lateral ischemia, there is no clinical correlation in this patient.
ANSWER
There are three findings on this ECG: unusual P waves consistent with a possible ectopic atrial rhythm, a prolonged QT interval, and T-wave abnormalities in the lateral leads.
Note that the P waves are negative in leads I and II, as well as in all chest leads. This is highly suggestive of an ectopic atrial rhythm originating low in the atria, conducting retrograde into the atria, and overriding the sinoatrial node. Limb lead reversal would result in negative P waves in lead I, but not in other leads.
A prolonged QT interval is determined by consulting any of the standard charts that correlate maximum heart rates with QT intervals and gender. In men, the QT interval is considered “prolonged” when it exceeds 440 ms, unless the heart rate is extremely slow.
Finally, T-wave inversions are present in the lateral leads (V5, V6). Although this may be an indication of lateral ischemia, there is no clinical correlation in this patient.
ANSWER
There are three findings on this ECG: unusual P waves consistent with a possible ectopic atrial rhythm, a prolonged QT interval, and T-wave abnormalities in the lateral leads.
Note that the P waves are negative in leads I and II, as well as in all chest leads. This is highly suggestive of an ectopic atrial rhythm originating low in the atria, conducting retrograde into the atria, and overriding the sinoatrial node. Limb lead reversal would result in negative P waves in lead I, but not in other leads.
A prolonged QT interval is determined by consulting any of the standard charts that correlate maximum heart rates with QT intervals and gender. In men, the QT interval is considered “prolonged” when it exceeds 440 ms, unless the heart rate is extremely slow.
Finally, T-wave inversions are present in the lateral leads (V5, V6). Although this may be an indication of lateral ischemia, there is no clinical correlation in this patient.
A 37-year-old man presents to your office to establish care. After being unemployed for two years, he recently obtained a position with a local manufacturing company and, as a result, has health benefits. He wants to “get checked out.” He has not seen a health care provider since having his tonsils removed at age 14. He says he is rarely ill, aside from an occasional cold. Besides the tonsillectomy, medical history is positive for a right clavicular fracture at age 6 and a left inguinal hernia repair at age 9. He had chickenpox and recalls that his immunizations were up to date until he graduated high school. His only medication is ibuprofen as needed for aches and pains. He has no known drug allergies. He uses two herbal supplements, fenugreek seed and horny goat weed, daily. He admits to recreational marijuana use. Family history is remarkable for coronary artery disease (father), diabetes (mother), and depression (sister). He consumes one six-pack of beer weekly and has smoked one pack of cigarettes per day for the past 23 years. He isn’t interested in quitting smoking. The patient is divorced, without children. He has been collecting unemployment since his last position was terminated due to budget constraints. A 20-point comprehensive review of systems is negative, with the exception of occasional palpitations and a productive morning smoker’s cough that quickly resolves. He states he’s “as healthy as a horse.” The physical exam reveals a thin, healthy-appearing middle-aged male. He is 72 in tall and weighs 167 lb. His blood pressure is 108/66 mm Hg; pulse, 70 beats/min and regular; respiratory rate, 14 breaths/min-1; and temperature, 98.4°F. The head, eyes, ears, nose, and throat (HEENT) exam is remarkable for poor dentition, with multiple caries readily visible. The tonsils are absent. Coarse expiratory crackles are present in both bases and clear with vigorous coughing. The abdominal exam is positive for a well-healed scar in the left inguinal crease. The remainder of the physical exam is normal. As part of a new patient visit, a chest x-ray and ECG are obtained. The ECG shows the following: a ventricular rate of 69 beats/min; PR interval, 178 ms; QRS duration, 90ms; QT/QTc interval, 442/473 ms; P axis, 231°; R axis, 84°; and T axis, 93°. What is your interpretation of this ECG?
