Basic Electrocardiography Normal and abnormal ECG patterns - Part 8 doc

A Left ventricular enlargement B Normal ECG variant; vertical heart with apparent levorotation C Normal ECG variant; horizontal heart D Normal ECG; heart with no rotation... A Right vent

QRS complex alternans

Rarely in relation with respiration especially in mid-precordial leads Cardiac tamponade

Supraventricular arrhythmias in WPW syndrome

ST–T alternans

Hyperacute phase of severe myocardial ischaemia Congenital long QT syndrome

Electrolytic imbalance

A

B

C

V 3

V 1

II

Figure 107 (A) Typical examples of electrical alternans (A) Alternans of QRS in a patient with pericardial tamponade (B) ST–QT alternans in Prinzmetal angina (C) Repolarisation alternans in important electrolyte imbalance.

To confirm whether you have understood the book and to check your ECG interpretative skills, we will proceed by conducting a multiple-choice test In this test, you will be asked to give a correct answer based on presented ECG recordings The examples of ECG tracings are based on the contents displayed

in the book

The correct answers as well as comments and explanations will be given

A

V1

V2

V3

Case 1

A young, asthenic man with no apparent heart disease The figure shows an ECG tracing in V1, V2 and V3 leads located in the second (A), third (B) and fourth (C) intercostal space What is the correct diagnosis?

A Atrial septal defect

B Partial right bundle branch block

C Brugada’s syndrome

D False image of right bundle branch block

121

Comment (A) Normal ECG recording, except V1, where final R wave is quite

prominent and final r in V2 and RS morphology in V3 are present Due to this morphology in V1 it is necessary to rule out RBBB The evidence that the

P wave in V1 is completely negative made us think that V1 lead is placed higher (second right intercostal space) and is recording the tail of the P vector (negative P) and the head of the third vector of ventricular depolarisation (terminal R) The lower location of the lead (B) decreased this image and it totally disappeared (positive P wave and rS in V1) when the lead was located correctly in fourth right intercostal space (C) We can conclude that in this case

a false pattern of RBBB is present due to incorrect position of V1–V2 leads The correct answer is D Occasionally, the Brugada syndrome can present similar morphologies to ‘A’ and also the morphology may change depending on the lead position; but in the Brugada pattern the rin V1 is wider and ST-segment elevation in V1–V2 is present (see Table 4)

III II

VR

VL

VF

V2

V3

V5

V6

Case 2

A 27-year-old man with no apparent heart disease What is the correct diagno-sis?

A Acute pericarditis

B Early repolarisation in a subject with a horizontal heart with levorotation

C Acute phase of a myocardial infarction

D Dextrorotated heart

Comment There is important levorotation (Rs in V2) with mild ST-segment

elevation starting from the J point, visible in V2–V4 This pattern corresponds

to the so-called early repolarisation pattern In the frontal plane with horizontal heart we can see qR in VL and rS in VF with ˆAQRS approximately−15◦and

in the horizontal plane levorotation is present (Rs in V2 and qR in V4) The exercise test normalises the ST-segment elevation in the early repolarisation pattern as it happened in this case, but not in acute pericarditis or the acute phase of MI Thus, the correct answer is B (see Figures 22D and 25-2a)

III

II

VR

VL

VF

V2

V3

V5

V6

Case 3

An 18-year-old lean man, asymptomatic, with no heart disease What is the correct diagnosis?

A Left ventricular enlargement

B Normal ECG variant; vertical heart with apparent levorotation

C Normal ECG variant; horizontal heart

D Normal ECG; heart with no rotation

Comment Vertical heart but without dextrorotation (there is no S in V5–V6).

On the contrary, it seems that there is levorotation, as large R (Rs) in V2–V3

is seen This can be explained knowing that in lean individuals with a long and narrow thorax, the heart is located more in the centre of the thorax and V3 already faces the left ventricle ST-segment elevation in V2–V3 from the early repolarisation type (asymmetric T wave) is seen The high voltage of the

R wave in V4 is striking (>30 mm) This value is higher than the accepted as

normal for adults, but can be observed in teenagers without heart disease and with normal echocardiogram, as it is in this case Thus, the correct answer is B (see Figures 22D and 25.1A)

B

–30°

+30°

+60°

+90°

+120°

+150°

–150°

+180°

I III

ÂQRS first part +30°, +40°

ÂQRS second part -140°, -150°

II VR VL VF

Case 4

A 28-year-old very lean man, with slight pectus excavatum, but with no apparent

heart disease What is the correct diagnosis?

A Right ventricular enlargement

B Normal heart with rotation on transversal axis (SI, SII, SIII)

C Superoanterior hemiblock

D Vertical heart

Comment ECG recording with SI SIISIII morphologies in the frontal plane Similar morphologies can be seen in right ventricular enlargement and, proba-bly, in the right superoanterior zonal block (see Table 6) The absolutely normal appearance of the P and T waves supports a normal heart with rotation type

SI, SII, SIII (transversal axis) (p 26) The presence of RS in V5–V6 is due to additional dextrorotation The extreme left deviation of ˆAQRS, in the case of superoanterior hemiblock, generates morphologies with SIIand SIIIbut with

SIII> SII, on the contrary, that in this case (see Figure 43B) The normal clinical observation of the patient, including the echocardiography and the absence of pulmonary involvement, also the age and the presence of pectus excavatum, together with the normal P and T waves, supports the diagnosis of the normal heart with rotation on the transversal axis The vertical heart presents RS in

I and qR in II and III Above: the QRS loop in such cases and the method of ˆ

AQRS calculation from the first and the second part of QRS Thus, the correct answer is B (see p 26 and Figure 43B)

I II III VR VL VF

Case 5

A 35-year-old man with no apparent heart disease What is the correct diagno-sis?

A Heart with no apparent rotation

B Vertical heart

C Horizontal heart

D Indeterminate electrical axis

Comment ECG of a heart without apparent rotations ˆAQRS at+30◦(rs in III and qR in VL and VF) The rest of the recording is in the normal range ˆAP=

0◦, ˆAT= + 30◦ Thus, the correct answer is A (see p 26 and Figure 24A)

III II

VR

VL

VF

V2

V3

V5

V6

Case 6

A 6-year-old child with no apparent heart disease What is the correct diagno-sis?

A Normal ECG

B Right ventricular overload

C Left ventricular enlargement

D Pericarditis

Comment Normal ECG for the age of the patient Observe the right ˆAQRS, the relatively tall R wave in V1 greater than ‘q’ in V6, the R wave of large voltage

in V4–V5, the deep ‘q’ wave in III, the infantile repolarisation, etc The ECG is normal Thus, the correct answer is A (see p 30 and Figure 27A)

V2

Case 7

These are leads V1 and V2 of a 60-year-old woman with a heart disease Which

is the correct diagnosis?

A Lateral myocardial infarction

B Significant enlargement of right cavities

C Complete right bundle branch block

D Type-II Wolff–Parkinson–White syndrome

Comment This ECG belongs to a 60-year-old patient with a long-standing

mi-tral and tricuspid valve disease, with a significant right ventricle and atrial enlargement (see the low-voltage qR pattern in V1 and the rS pattern in V2 with a much higher voltage) The patient was in atrial fibrillation, with not visible ‘f’ waves Spontaneously, she converted to normal sinus rhythm with

a P wave that was only visible, but quite small, in V1–V2 Most probably, the presence of a significant atrial fibrosis could explain that large atria, as demon-strated in the echocardiographic study, generate a barely visible voltage in the surface ECG Occasionally, even normal sinus rhythm can be completely concealed The ECG does not show the presence of a complete right bundle branch block, as the QRS complex is narrow, nor does it show the presence of a Wolff–Parkinson–White syndrome, as the PR segment is not short, nor does it suggest the presence of a lateral infarction, as the morphology is not that of an

R or Rs complex with a positive T wave, but of a qR complex with a negative

T wave Therefore, the correct answer is B (see p 35 and p 40)

III

II

VR

VL

VF

V2

V3

V5

V6

Case 8

This is a 45-year-old patient suffering from a heart disease, with the diagnosis having been made 30 years ago Which is the correct diagnosis?

A Significant left ventricular and atrial enlargement

B Complete left bundle branch block

C Superoanterior hemiblock

D Acute septal infarction

Comment This is a patient with a valvular heart disease presenting a significant

left ventricular enlargement (LVE), with a pure R wave in lead V6 with a systolic overload pattern and an S wave in V2+ an R wave in V6 = 45 mm The P wave

is wide and± in leads II, III and VF, and from V1 to V4 It corresponds to a typical complete interatrial block with left atrium retrograde conduction that is always associated with left atrial enlargement Therefore, the correct answer is

A The other diagnoses can be ruled out (1) Complete left bundle branch block: the QRS complex is not equal to or longer than 0.12 seconds (2) Superoanterior hemiblock: ˆAQRS is not beyond−45◦ (3) Acute septal infarction: there is no

QS complex in V1–V2, and the ST-segment elevation, which is convex with respect to the isoelectric baseline, may be explained as a mirror image of the LVE morphology that is seen in V6 (see p 37 and p 44)

III

II

Y

Z

VL

VF

V 2

V 3

V 5

V 6

Case 9

This is a 65-year-old patient The history taking is normal, with antecedents

of chronic obstructive pulmonary disease dating back more than 20 years (re-cently with an acute crisis) Which is the correct diagnosis?

A Right ventricular and atrial enlargement

B Complete right bundle branch block

C Acute coronary syndrome with a negative T wave from V1to V3

D Normal variant (vertically orientated heart) with no associated disease