Inferior wall with posterior wall with right wall myocardial infarction

A 56-years old female comes with acute onset retrosternal chest pain of 6 hours duration along with palpitation, sweating, giddiness and dyspnoea. She was a known case of diabetes mellitus and hypertension since last 10 years. Her pulse at the time of admission was 68 beats per minutes, blood pressure 90/60 mmhg. ECG of patient at the time of arrival is shown below

First ECG of the patient 

 ECG is showing sinus rhythm at 70 beats per minutes, normal axis, there is ST segment elevation in lead II,III, Avf. There is marked ST segment depression in lead I, avL along with T wave inversion in lead avL Lead V1,V2,V3 is showing ST segment depression with ST segment flattening along with upright tall T wave (most prominent in lead V2), ratio of R wave / S wave in lead V2 is more than 1. So the ecg is suggestive of acute inferior wall myocardial infarction along with posterior wall myocardial infarction.

ECG with posterior lead (Posterior lead indicated by lead V4,V5,V6)

ECG is showing ST segment elevation in lead V4,V5,V6(representing posterior lead V7,V8,V9)

ECG with right sided lead (represented by lead V4,V5,V6)

ECG is showing ST segment elevation in lead V4,V5,V6

Patient was started on thrombolysis. ECG done 30 min after starting thrombolysis

 ECG is still showing ST segment elevation in lead II,III,avF along with ST segment depression in lead V2,V3

ECG done 6 hours after thrombolysis

There is significant ST segment resolution after thrombolysis ( more than 50% ST segment resolution suggestive of successful thrombolysis.

Little about ECG finding in posterior wall myocardial infarction

Posterior wall myocardial infarction (MI) occur due to occlusion of either the left circumflex or the right coronary artery. It most commonly occur with acute inferior or lateral MI; but isolated posterior wall MI can occur. 

Electrocardiographic abnormalities suggestive of acute posterior wall MI include  (in leads V1, V2, or V3): 

(1) Horizontal ST segment depression

(2) Tall, upright T wave;

 (3) Tall, wide R wave

 (4) R/S wave ratio greater than 1.0 (in lead V2 only). 

Combination of horizontal ST segment depression with an upright T wave increased the diagnostic accuracy of these two separate electrocardiographic findings. 

The additional-lead electrocardiogram using left posterior thorax leads is potentially helpful; ST segment elevation greater than 1 mm in this distribution suggests an acute posterior wall MI

Reference
Brady WJ. Acute posterior wall myocardial infarction: electrocardiographic manifestations. The American journal of emergency medicine. 1998 Jul 1;16(4):409-13.

Thank you.

PSVT

A 50 years old female came to the emergency with chief complaints of acute onset palpitation since last one hour of duration. There was no history of dyspnoea, chest pain, giddiness. Patient was a known case of diabetes mellitus since last 10 years and hypothyroidism  since last 7 years. During admission patient blood pressure was 126/70 mmhg. ECG of  the patient is shown below.

ECG during episode of tachycardia (Click  on the image to enlarge it)

ECG is showing narrow QRS complex (QRS duration in the ecg is less than 120 msec), regular tachycardia at rate around 190 beats per minutes, no visibble P wave seen anywhere, no significant ST-T wave changes are seen so the ecg is suggestive of narrow complex regular Short RP( P wave not seen, it mean P wave are most likely merged in the QRS complex, so RP interval(from the start of QRS complex to the start of P wave) is very small or < 70 msec, tachycardia. 

Differential is first most likely Atrioventricular nodal reentrant tachycardia (AVNRT), second AVRT, third atrial tachycardia.Patient was given injection adenosine, following which she achieved normal sinus rhythm. 

ECG after giving injection adenosine is shown below (Click on the image to enlarge it)

ECG is showing  normal sinus rhythm at 100 beats per minute, normal axis, PR interval 120 msec, no ST-T wave changes seen.

Patient underwent Electrophysiology study which showed dual Atrioventricular nodal physiology suggestive of AVNRT. Patient underwent successful slow pathway ablation.

Let's discuss how to approach in a patient with narrow QRS complex, regular tachycardia.

Thank you.

Acute posterior wall myocardial infarction with inferior wall myocardial infaction

A 59-years-male came with history of acute onset retrosternal chest pain of 2 hours duration. He was a chronic smoker and known case of diabetes mellitus since last 6 years and was on oral hypoglycemic agent for the same. Patient was also complaining of dyspnea, orthopnoea and paroxysmal nocturnal dyspnoea. Patient went to local hospital, ECG was done, which was suggestive of ST elevation myocardial infarction. Patient was immediately thrombolysed with tenecteplase. Patient was intubated, kept on ventilator in view of acute congestive heart failure and left ventricular dysfunction and referred to our hospital . During evaluation in emergency patient pulse was 100 beats per minute, Blood pressure 80/60 mmhg, on respiratory system examination bilateral crepitations were present.

First ECG of the patient 

ECG  of the patient is showing heart rate of 125 beats per minute, narrow QRS complex, PR interval 160 msec duration, there is ST segment elevation in lead II,III,avF. Also there is marked ST segment depression with ST segment flattening in lead V1,V2, V3. T wave in lead V1-V3 are all and upright, Tall and broad R wave in lead V1,V2, R wave in lead V1,V2 of 40 msec ( one small square), R/S ratio in lead V2 is equal to 1 (R wave height is 6 small square, and S wave depth is also 6 small square) so ecg is suggestive of posterior wall myocardial infarction.

ECG done after 5 minute

ECG is showing ST segment elevation in lead II,III, avF. There is marked ST segment depression in lead V1-V3 so the diagnosis of this patient is inferior wall myocardial infarction with posterior wall myocardial infarction.

Patient posterior lead ECG could not be done as patient was on ventilator. Patient was thrombolysed.

 

Post Thrombolysis ECG of the patient

ECG is showing normal sinus rhythm at 100 beats per min, normal axis, there is small Q wave seen in lead II,III,avF. Also mild ST segment elevation or upward convexity seen in lead II,III. There are tall T wave seen in lead V2. so ECG is suggestive of successful thrombolysis as there is ST segment resolution in the ECG.

So the final diagnosis is ST elevation posterior wall myocardial infarction with inferior wall myocardial infarction with successful thrombolysis.

Little about ECG finding in posterior wall myocardial infarction

Posterior wall myocardial infarction (MI) occur due to occlusion of either the left circumflex or the right coronary artery. It most commonly occur with acute inferior or lateral MI; but isolated posterior wall MI can occur. 

Electrocardiographic abnormalities suggestive of acute posterior wall MI include  (in leads V1, V2, or V3): 

(1) Horizontal ST segment depression

(2) Tall, upright T wave;

 (3) Tall, wide R wave

 (4) R/S wave ratio greater than 1.0 (in lead V2 only). 

Combination of horizontal ST segment depression with an upright T wave increased the diagnostic accuracy of these two separate electrocardiographic findings. 

The additional-lead electrocardiogram using left posterior thorax leads is potentially helpful; ST segment elevation greater than 1 mm in this distribution suggests an acute posterior wall MI

Reference
Brady WJ. Acute posterior wall myocardial infarction: electrocardiographic manifestations. The American journal of emergency medicine. 1998 Jul 1;16(4):409-13.

Thank you.

Presyncope in a middle age male

A 54-years male came with history of giddiness on and off along with one episode of blurring of vision since last one day. There was no history of Diabetes mellitus, hypertension or coronary artery diseases.

ECG done in the emergency department is shown below (Click on the image to enlarge it)

ECG is showing sinus bradycardia with heart rate of 50 beats per minute, PR interval was 140 msec, there was right axis deviation with complete right bundle branch block, QTc interval was 386 msec.

So from history and ecg we kept the possibility of Presyncope with Possible Sinus node dysfunction with intraventricular conduction defect. But ECG was not completely diagnostic. So holter was done.

Holter of the patient 

Holter of patient showed bradycardia with average heart rate around 50 beats per minute, there were long sinus pause maximum being of 4 sec during awake time, there was decrease heart rate variability but there was no evidence of any atrioventricular block. So in view of these holter finding patient underwent dual chamber pacemaker and later discharged in stable condition.


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Middle age female came with palpitation, ECG showing narrow complex tachycardia

A 55 -years old female came with history  of palpitation of one hour duration. She was a known case of diabetes mellitus and hypertension since last 10 years and was on medical treatment for the same. ECG of the patient done in the emergency department is shown below.

ECG during the episode of  tachycardia

ECG is showing narrow complex regular tachycardia at rate 180 per minute, normal axis, no visible P wave seen, there were no ST-T wave changes seen. So the ecg diagnosis of the patient was kept narrow complex, regular, short RP (as P wave not visible ) tachycardia with differential diagnosis being AVNRT, AVRT, Atrial tachycardia.

Patient was given injection adenosine following which her tachycardia subsided.

ECG after giving injection adenosine

ECG is showing normal sinus rhythm at rate 114 beats per minute, normal axis, no pre-excitation visible.

Patient underwent electrophysiological study which showed dual AV nodal physiology. Patient underwent successful slow pathway ablation and was discharged in stable condition.

Lets discuss how to approach in a patient with Short RP regular, narrow complex tachycardia.

Thank you.

Assessment of severity of AR by echocardiography

PSVT

A 21-year old female came with history of palpitation on and off since last five year. 

ECG 1 (Click on the image to enlarge it)

ECG is showing narrow qrs complex regular tachycardia. I can not see any clear P wave or probably few doubtful P wave merged in the qrs complex seen at the end of qrs in lead II. So it is a short RP tachycardia. There were no ST- T wave changes.

ECG after giving adenosine injection (Click on the figure to enlarge it)

ECG is showing normal sinus rhythm at 75 beats per minutes, PR interval 130 msec, no evidence of any delta wave or any pre-excitation any where seen in the ecg. There are no ST-T wave changes.
So the final diagnosis of this patient is Short RP tachycardia and differential could be AVNRT, Atrial tachycardia or AVRT. Because P wave are merged into the qrs complex or very near the QRS complex(if i take negative complex seen in figure 1 in lead II), then the RP interval is less than 70 msec so most likely diagnosis is AVNRT.

Patient underwent Electrophysiological study and it show dual AV node physiology with AVNRT. Patient underwent successful radiofrequency ablation of slow pathway. Post ablation there is no evidence of any tachycardia. Patient was discharged in stable condition.

Let's discuss how to approach in a case of Narrow QRS complex tachycardia.

Thank you.

Anterior wall myocardial infarction

A 52-year-male came to JIPMER hospital with history of acute onset retrosternal chest pain since 4 hours of duration along with palpitation, perspiration, giddiness, dyspnoea. There was no history of orthopnea, PND, syncope. His BP was 140/80 mmhg, Pulse 104 beats per minute, saturation of oxygen was 96%. Patient serial ECG were done which are shown below.

ECG 1

ECG is showing normal sinus rhythm at 100 beats per minute, normal axis, normal PR interval (120 msec), there is mild ST segment depression in lead I,avL (1 mv), there were no other significant ST-T wave changes seen.
Patient was kept under constant observation. His cardiac marker were sent and he was started on antiplatelet therapy along with heparin. But patient chest pain did not improve and suddenly he develop ST elevation acute anterior wall myocardial infarction after 3 hours of presentation.

ECG 2 (3 after presentation)

ECG is showing ST elevation in lead V2-V6 with hyperacute Tall T wave. Also there is mild ST segment elevation in lead I, avL.

ECG 3

ECG is showing ST elevation extensive anterolateral wall myocardial infarction. Patient was immediately started on streptokinase therapy. His post thrombolysis ECG is shown below

ECG 4(Post thrombolysis)

 ECG is showing qRBBB in lead V1, with QS complex in lead V1-V4, ST segment elevation in lead V1-V6, I,avL, also there is ST segment depression in lead II,III,avF.

ECG 5 (Post thrombolysis) 

ECG is showing qRBB with QS complex in lead V1-V5, avL suggestive of failed thrombolysis in this patient.

So the final diagnosis is Acute extensive anterior wall myocardial infarction with failed thrombolysis.

Thank you.

Inferior wall myocardial infarction presenting as complete heart block to Type II AV block

A 50 year old male presenting with history of giddiness along with 3 episode of vomiting since 4 hours of duration. There was no history of chest pain, palpitation, sweating, syncope. Patient was non diabetic, non hypertensive. His pulse was 50 beats per minute, BP-110/70 mmhg during the time of admission. Patient ecg done in the emergency department is shown below.

ECG 1 (Click on the image to enlarge it)

ECG of the patient is showing complete AV dissociation with ST segment elevation in lead III, avF, but elevation was less than 1 mv......

ECG 2 taken after 10 min

ECG  is still showing same finding as in first ECG

ECG 3

ECG is showing ST segment elevation in lead III, very mild ST segment elevation in lead II, avF

 ECG 4 done after 30 min

ECG is showing ST segment elevation in lead II,III, avf, with  hyperacute Tall T wave, now instead of complete AV block there is 4:3 type I 2nd degree AV block (Wenckebach block) with group beating present.

ECG with right sided lead

ECG is not showing any evidence of right sided infarction as there is absence of ST segment elevation in right sided lead.


Patient was immediately started on thrombolysis.

Post thrombolysis  ECG is shown below

ECG is showing complete resolution of ST segment along with resolution of AV block. PR interval is although borderline prolonged, PR interval after thombolysis is 160 msec.

ECG done next day

ECG become completely normal next day. There is no evidence of AV block, neither any evidence of ST segment elevation.

Next day patient underwent coronary angiography which shows 70-80% stenosis in Mid right coronary artery(RCA) rest of the vessel were normal.

So the final diagnosis of the patient is IWMI with complete heart block with successful thrombolysis with Single vessel diseases of RCA.

Thank you.

Middle age female came with palpitation ??? what is your diagnosis

A 50-year-old female came to JIPMER hospital with chief complaints of acute onset palpitation since last 1 hours , which were acute in onset was not associated with nausea, vomiting, giddiness or syncope. Patient was giving similar history since last on and off since last 2 years.  Patient was non diabetic, non hypertensive. Her tachycardia ECG is shown below.

ECG 1(Click on the image to enlarge it)

ECG of the patient is showing narrow complex regular tachycardia at heart rate of 188 beats per minute, normal axis, QRS duration 80 msec, P wave have merged into the T wave and producing  ST segment depression in lead I,avL, II,III,aVF, V5,V6. Kindly see lead III, avL, i think those are the inverted P wave so the RP interval is 160 msec and PR interval is 200 msec, so it is short RP tachycardia.

ECG 2(Showing Precordial lead)

Precordial lead of the patient is showing narrow complex, regular, short RP tachycardia.

So the differential diagnosis in this patient is either AVRT or AVNRT. Because the RP interval is more than 70 msec so the possibility of AVRT was more compared to AVNRT.

In view of her continuous palpitation initially vagal maneuver was tried but it was not successful so patient was given intravenous adenosine 6 mg via antecubital vein. Her tachycardia subsided after giving adenosine. Her sinus ecg is shown below.

ECG after giving injection adenosine

ECG is showing normal sinus rhythm at 73 beats per minute, normal PR interval, no ST-T wave changes, normal axis.
Patient underwent Electrophysiological study which shows orthodromic AVRT with left accessory pathway. Interatrial septal puncture was done and successful ablation was done.

So the final diagnosis of this patient is Orthodromic AVRT with left sided pathway.

Now lets discuss how to approach in a patient with Narrow complex tachycardia.

Thank you.

Variable AV block, 2:1 AV block converting into 3:1 AV block

A 68-year old female came to JIPMER Hospital, Pondicherry, India with chief complaints of giddiness on and off since last 3 days along with dyspnoea on exertion NYHA II. Patient was a known case of hypertension and she was on beta blocker. ECG of the patient is shown below.

ECG 1(Click on the image to enlarge it)

ECG of the patient is showing bradycardia with heart rate around 50 beats per minute, normal axis, normal QRS duration, there are two P wave for every one QRS complex, PR interval is fixed, around 120 msec, so the ecg is suggestive of 2:1 AV block, it could be 2 nd degree Type 1 or Type II AV block. As the patient was on betablocker so the drug was stopped. Her ecg done after 2 days is shown below.

ECG after 2 days of stopping beta blocker

ECG is now showing 3:1 AV block, so the block had progressed instead of improving in spite of stopping beta blocker so it means this patient is having significant AV node diseases. In view of her ecg changes she was advised to undergone permanent pacemaker. Following this patient successfully underwent permanent pacemaker insertion (VVI).

Thank you.

WPW Syndrome

A 13-years-male came to JIPMER Pondicherry hospital cardiology OPD  with chief complaints of palpitation on and off since last one year, history of syncope 3 episode over last 15 days along with atypical chest pain. ECHO of the patient was normal. ECG of the patient is shown below.

ECG 1(Click on the image to enlarge it)

Sinus rhythm at 90 beats per minute, left axis, PR interval 80 msec, Positive delta wave seen in leads 2,3,avf, negative delta wave seen  in lead V1, ST segment depression present in lead I,II, III, avF, V5,V6. So the ECG of the patient was suggestive of WPW syndrome with Right free wall pathway. 

In view of history of palpitation and syncope patient underwent Electrophysiological study which show Right free wall accessory pathway with preexcitation. Patient underwent successful ablation. 

Post ablation ECG is shown below.

ECG 2 (Click on the image to enlarge it)

ECG is showing Normal sinus rhythm at 75 beats per minute, normal axis, no pre-excitation seen. There is Deep T wave inversion in lead V1,V2 also there is T wave inversion seen in lead V3 suggestive of memory T wave post ablation therapy.

WPW Syndrome


Algorithm for  pathway localisation

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