Welcome to another installment of Name that ECG! Remember, this is a cold read and your job is to interpret the ECG to its fullest.
66 year old female, resolved chest pain.
Rhythm:
- Rate?
- Regularity?
- P-waves?
- PR interval? Associated?
- QRS width?
Bonus points:
- Axis?
- QTc?
- ST/T-wave changes?
What are your differentials?
Posts which include any permutation of the phrase "treat the patient not the monitor" will be deleted and their author beaten with a LifePak 5.
Interpretation: Sinus Brady @ 50-60 (based on upright P waves in I, II, III, avf and negative p wave in avr and hr < 60 w/ regular rhythm), Left Axis Deviation, LAFB(LAD, qr in I/AVL, rS in II, III, Avf), Biphasic T waves in V2, V3, V4 highly suggestive of Wellens Syndrome. Inverted T wave in AVL.
Cheers!
Wellen's Syndrome with some left axis deviation?
•Rate?
About 60
•Regularity?
Regular
•P-waves?
Yes
•PR interval? Associated?
Borderline for 1st degree AVB. 1:1 association
•QRS width?
Normal at 0.08s
•Axis?
Left (positive QRS in I, negative QRS is aVF)
•QTc?
Less than half the RR interval so probably ok
•ST/T-wave changes?
Wellens waves in V2-V5
TWI in I and aVL
Which all points to partial LAD occlusion but isn't enough to activate a cath lab?
Rate is about 60 bpm, regular rhythm P waves are these, PRI is good, QRS is wide with LBBB, LAD is seen..QTc is normal, Biphasic T waves seen with negative terminal – first stage of Wellens syndrome…urgent but not immediate cath…R waves are there meaning the artery is not yet infarcted…there is spontaneous reperfusion..
I definitely say it’s textbook wellen’s syndrome. Inversion in AvL and hyper acute-ish looking T waves inferiorly kinda makes me think Type III wraparound LAD occlusion due to possible inferior injury with the more obvious anterior injury. Happy holidays kids!
@Ryan Tee – I'm not seeing any evidence of left bundle-branch block (LBBB). In fact, if LBBB was actually present, then it would probably mask the ST-T changes of "Wellens' warning". The duration of the QRS interval is normally narrow at 0.08s and there are triphasic "qRs" complexes in both lead I and V6.
Rhythm: Sinus bradycardia
Rate? 56
Regularity? Yes.
P-waves? Yes.
PR interval? Associated? 0.16s. Yes.
QRS width? 0.08s.
Bonus points:
Axis? QRS -30 degree. Z +40.
QTc? 425 ms.
ST/T-wave changes? Biphasic T-waves V1-V5. Retrograde in aVL.
What are your differentials? LAD occulsion. I have nothing else to add to my DDx.
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56, sinus bradycardia, LAFB, LAE, anteroseptal ischemia.
Rate: 56
Rhythm: Regular, p-waves present, P:QRS 1:1, PRi about 0.16s, QRS narrow 0.08s. Sinus bradycardia.
Axis: QRS – I +, avF -, II -, -30 degree, LAD, LAFB (qR in I, rS in III too).
Z V4 +40m, V1-V3 looks like the leads were placed 1 ICS too high (V3 r-wave >3 mm).
Enlargement/Hypertrophy: Left atrial enlargement (2nd 1/2 of P-wave in V1 >0.04s, 1mm deep)
ST/T, Q: insignificant q-waves in I and aVL. Significant Q in II and aVF. III has a small r-wave. No significant STE, but V1-V5 has retrograde T-waves. V2-V3, are those Wellen's T-waves? aVL also has a retrograde T-wave.
QT 440 ms.
QTc 425 ms.
I'd be concerned about LAD occulusion cause of the T-waves in the anteroseptal leads.