Inferior wall myocardial infarction with right sided extension with ventricular ectopy

A 63 Yr/Female, known case of hypertension came to JIPMER hospital, Pondicherry with chief complaint of acute onset chest pain of 3 hours duration. ECG of the patient is shown below.

ECG 1 (Click on the image to enlarge it)

ECG is showing sinus rhythm at rate around 100 beats per minute, PR interval 200 msec, there is ST segment elevation in lead II,III, avF, V3, V6ST segment depression present  in lead I, avL, V2, V4, V5, intermittent ventricular ectopy seen of LBBB morphology, QT interval 360 msec, QTc 465 msec,so the ECG is suggestive of inferior wall myocardial infarction with later extension in view of ST segment elevation in lead V6

ECG 2

Right side of the ECG 3

Right side lead of the patient is showing ST segment elevation in lead V3-V6 suggestive of right sided infaction.

Patient immediately underwent thrombolysis, post thrombolysis ECG of the patient is shown below

ECG 4

Post Thrombolysis ECG is showing successful ST segment resolution in inferior lead.



Thank you.

Praveen Gupta

Left posterior fascicular tachycardia

A 37 Yr/Female came to JIPMER, Pondicherry, hospital with chief complaints of palpitaion on and off since last two month. Patient had two episode of palpitation and they were reverted with DC shock at private hospital. Patient was also giving history of similar episode 5 years back. There was no history of giddiness, syncope, diabetes mellitus, hypertension or coronary  artery diseases. During evaluation in cardiology OPD her pulse was 75 beats per minute, BP-110/70 mmhg, ECHO heart was normal. She underwent Cardiac MRI at private hospital which was also normal.

ECG 1(Click on the image to enlarge it)

ECG of the patient is showing regular, broad complex tachycardia,  Left axis deviation, RBBB morphology, RR1 in lead C1, rS complex in lead V6, there is no visible P wave, no capture beat, no fusion beat, QRS duration is 200  msec so the differential diagnosis is Either ventricular tachycardia originating from Left ventricle, most likely from posterior papillary muscle or it could be supraventricular tachycardia with aberrancy ( Although the possibility of later is very less).

Another Tachycardia ECG of the patient

Another Tachycardia ECG of the patient

Sinus ECG of the patient

Sinus ECG of the patient is showing Normal sinus rhythm at rate around 75 beats per minute, normal axis, incomplete RBBB, narrow QRS complex, no st-t wave changes seen, QT interval 400 msec, QTC 447 msec.

So the diagnosis of this patient is most likely left posterior fascicular tachycardia.
Patient  was admitted in JIPMER Cardiology department and she underwent EPS study which conform our diagnosis.


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Complete heart block ecg

A 65 yr/female came to JIPMER hospital, Pondicherry, India with chief complaints of atypical chest pain since one month. She was recently diagnosed as a case of Hypertension and was on antihypertensive medication. There was no history of diabetes mellitus, angina dyspnoea on exertion, giddiness, syncope, or coronary artery diseases. During examination her pulse was 45 beats per minute, regular, BP=148/78 mmhg. Patient ECG is shown below with rhythm strip 

ECG 1(Click on the ecg to enlarge it)

Rhythm strip 1

So the ECG of the patient was suggestive of complete heart block (Most likely high grade block). She underwent permanent pacemaker insertion and later discharged in stable condition.


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Atrial fibrillation in a 12 year old male child

A 12 year old male child came to  JIPMER Hospital, Pondicherry, India with chief complaints of palpitation since 2 hours of duration. There was no history of giddiness, vomiting, chest pain, or breathless. There was NO past history of HTN/DM/RHD/CAD. Patient BP-110/70 mmhg, Pulse was 160 beats/min. ECG of the patient done in the emergency department is shown below.

ECG 1(Tachycardia ECG)(Click on the ecg to enlarge it)

ECG is showing narrow complex tachycardia at rate around 152 beats per minute,  irregular in nature, Left axis deviation, no visible P wave seen,ST segment with T wave inversion present in lead II,III,avF, V3-V6 so the diagnosis is atrial fibrillation with Left ventricular strain pattern

Rhythm strip of the patient

Rhythm strip of the patient show narrow complex irregular tachycardia with rate around 150 beats per minute.

ECHO heart of the patient was suggestive of severe concentric LVH with septal thickness around 18 mm and posterior wall thickness around 18 mm. There was no evidence of HOCM in the form of LVOT gradient.
 Patient BUN/Serum creatinine were within normal range. No evidence of Hypertension during his stay in the hospital.

Patient was given  intravenous amiodarone and he was converted to normal sinus rhythm. Later patient was started on tablet diltiazem.Patient was also started on aspirin in view of his CHADS2 score being 0. Presently patient is under workup to look for the etiology of concentric LVH, Atrial fibrillation.

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PSVT patient develop CHB post radiofrequency ablation

A 81 yr/male was admitted to JIPMER hospital, Pondicherry, India with chief complaints of palpitation on and off since last 4 years. Patient was a known case of diabetes mellitus since last 4 yr and was on medical management.  Patient ECG done which was suggestive of Paroxysmal supraventricular tachycardia.

ECG of the patient (Click on the image to enlarge it)

ECG is showing narrow QRS, regular tachycardia at rate around 188 beats per minute, clearly visible P wave were not seen, few doubtful P wave merged into QRS complex seen in lead V1??Pseudo R wave , no other ST-T segment changes seen, so the ecg is suggestive of narrow complex tachycardia differential diagnosis being AVNRT most likely.
Patient underwent radiofrequency ablation for the PSVT. Following ablation ECG of the patient suggestive of high grade block.

ECG 2 

ECG is showing sinus bradycardia at rate 54 beats per minute, PR interval around 240 msec, QT interval 400 msec, QTc 380 msec, so pre-excitation seen, No ST-T wave changes seen.


                               ECG 3 suggestive of Complete heart block(Click on image to enlarge it)

 ECG is suggestive of heart rate around 60 beats per minute, there is complete AV dissociation, there is no consistent relationship between P wave and QRS complex, QRS complex of narrow in morphology, atrial rate around 100 beats per minute so the ECG is suggestive of  Complete heart block.

Patient underwent successful Pacemaker ablation and was discharged in stable condition.

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Atrial tachycardia

A 64 yr/male, resident of Karaikal, Pondicherry (South India), came to JIPMER hospital with history of palpitation on and off since last one week along with giddiness. There is no history of syncope, nausea, vomiting, angina, dyspnoea, orthopnea or Paroxysmal nocturnal dyspnoea. Patient was a known  case of Diabetes mellitus and hypertension since last 5 years and was on regular medication. During evaluation in the emergency department patient pulse was around 200 beats per minute, regular in rhythm, normal volume, BP=130/70 mmhg, Respiratory and cardiovascular system were normal. ECG of the patient done in the emergency department is shown below.  

ECG 1 (Click on the image to  enlarge it)

ECG 2 (Rhythm strip)

Narrow complex, regular tachycardia,Rate around 200 beats per minute, Clearly visible P wave not seen, but few doubful P wave are seen in lead II,III,avF, V5,V6, RP interval 180 msec,PR interval 160 msec No significant ST-T wave changes seen.
Diagnosis is ???Long RP tachycardia
Diferential diagnosis = Atrial tachycardia, Atypical AVNRT, PJRT

Patient was given injection adenosine to further both to treat and investigate the cause of tachycardia. Patient was given two times 12 mg injection adenosine. Post adenosine ECG is shown below. Tachycardia terminate for few second but again recur

                Post adenosine rhythm strip of the patient still shows on going tachycardia

So patient was given injection dilzem 15 mg slowly intravenously, tachycardia  rate subsided slowly after few seconds. Patient acheive normal sinus rhythm. ECG of the patient in  sinus rhythm is given below

                                                      ECG 4 (Sinus ECG)

ECG  showing heart rate around 100 beats per minutes,there is presence of normal sinus beats along with few premature atrial contraction, normal PR interval, normal axis, No ST-T wave changes are seen,there is no evidence of pre-excitation in the baseline ecg in the form of delta wave.

Patient underwent EPS/ablation at JIPMER, Cardiology department. EPS was suggestive of Atrial tachycardia with origin from left atrium, posterior in location. Patient underwent successful ablation. Patient also underwent Coronary angiography in view of his risk factor of DM and HTN to rule out coronary artery disease. Coronary angiography was suggestive of Non obstructive coronary artery disease of LAD/RCA. Patient was started on medical management for that.
Lets discuss how to  approach in a patient of Narrow complex tachycardia.

Thank  you.

Ventricular tachycardia

A 43 year old male came to JIPMER Hospital with chief complaints of palpitation since last 3 days which was acute in onset, intermittent to continuous in nature, regular in nature, associated with chest pain and giddiness.Palpitation were associated with history of nausea and one episode of vomiting. Patient was a known case of hypertension since last 7 years and was on regular treatment. Patient was also giving history of acute anterior wall myocardial infaction in 2014, for which he was treated at private hospital. Coronary angiography done at that time was suggestive of single vessel diseases of Left anterior descending coronary artery for which PCI was tried but it got failed. Patient was on medical management since that time. But again in Nov 2016 patient develop acute onset chest pain with palpitation, sweating for which he was investigated at private hospital and diagnosed to have Acute coronary syndrome/unstable angina. Medical management was given. Coronary angiogram was suggestive of single vessel disease of LAD ( 100% stenosis)  with chronic total occlusion. ECHO was done , which was suggestive of severe left ventricular dysfunction (LVEF=35%) with moderate mitral regurgitation with left ventricular apical aneurysm and he was started on prophylactic amiodarone, antiplatelets, beta blocker and ACE inhibitor.Patient was asymptomatic but he develop recent episode of palpitation. Patient went to private hospital, ECG done, BP at that time was 70 mmhg, DC cardioversion was done follwing which patient was refeered to JIPMER Pondicherry Hospital for further management. ECG of the patient during the episode of tachycardia is given below.

ECG 1 (Click on the image to enlarge it)

ECG 2

ECG 3

Description of the ECG-Broad complex regular tachycardia at heart rate around 190 beats per minute, QRS of RBBB morphology, QRS duration 240 msec, normal axis, there were no capture beats, no fusion beats, no AV dissociation seen, no visible P wave seen, negative concordance seen from lead V1-V6, rS seen in lead V6, 

 ECG 4 (After giving DC cardioversion)

 

Description of the ECG-Noraml sinus rhythm at rate 86 beats per minute, LAD,LAHB, RBBB, QS wave seen in lead V1-V6

So from both the above ecg the diagnosis of this patient is Ventricular tachycardia. 

Lets discuss how to approach in a patient with Broad complex  tachycardia

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Atrial tachycardia

A 62 year old female came to JIPMER cardiology OPD with history of acute onset breathlessness along with giddiness 10 days back. Patient went to  local government hospital. ECG of the patient was done and following which patient was referred to JIPMER hospital for further management. During evaluation at JIPMER hospital patient pulse was 80 beats per minute, irregular, BP 110/70 mmhg. Patient was a known case of Diabetes mellitus. There was no history of Hypertension, coronary artery diseases. ECG of the patient done at JIPMER hospital is shown below.

ECG (Click on the image to enlarge it)

Description of the ECG- Narrow complex irregular tachycardia at around 160 beats per minute, normal axis, P wave seen, P wave are positive in lead V1, I, PR interval 160 msec, RP interval 200 msec, ST segment depression with T wave inversion present in lead V4-V6, so the diagnosis is atrial tachycardia.

Approach in a patient with narrow complex tachycardia

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Ventricular tachycardia in young male

A 19 years old male came to JIPMER hospital  with  chief complaints of palpitaion since two month along with dyspnoea on  exertion NYHA class I. There was no history of giddiness, syncope, chest pain, orthopnea or PND. During evaluation patient pulse was 98 beats per minute, BP 110/70 mmhg, CVS S1S2 were normal, RS Bilateral normal vesicular sound were present. ECG of the patient is shown below.

ECG 1

Broad complex regular rhythm at heart rate around 100 beats per minute, RBBB  morphology, LAD,Early transition present in lead V1, V2, Positive concordance present, intermittent capture beats seen which are narrow complex with PR interval of  160 msec, QT interval 320 msec so the ecg is suggestive of ventricular tachycardia

ECG 2 of the patient

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