Ventricular flutter in a patient with anterior wall myocardial infarction

A 29 years old male who had the history of acute onset retrosternal chest pain of two hours duration, went to outside hospital.  The patient had the history of recently diagnosed diabetes mellitus and family history of coronary artery diseases.

ECG of the patient  is shown below

 
ECG is showing sinus tachycardia with a heart rate around 130 beats per minute, normal axis, PR interval of 160 msec, there is marked ST-segment elevation seen in lead V2-V6, I, avL, II, III, avF, QT interval of 320 msec suggestive of extensive anterior wall myocardial infarction.
Patient was immediately thrombolysed. ECHO suggestive of severe left ventricular systolic dysfunction. Post thrombolysis coronary angiogram of the patient showed mid LAD Total occlusion. PCI  with stenting to LAD done. Post PCI patient develops acute onset episode of palpitations and giddiness.

ECG of the patient after stenting

ECG is showing sine wave pattern with no clearly seen QRS complex or P wave or ST segment or T wave. Heart rate around 300 beats per minute so the ECG is suggestive of ventricular flutter.

Another ECG of the patient

ECG is showing ventricular flutter. The patient develops hypotension. The patient was immediately given DC shock, injection amiodarone, and CPR but he could not be revived and he died due to cardiac arrest.


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Praveen Gupta

Left ventricular hypertrophy with LV strain pattern

A 51 years old male who was a known hypertensive since last 10 years, came for routine evaluation. Patient ECG is shown below

ECG (Click on the image to enlarge it)

ECG is showing Sinus rhythm at rate 80 beats per minutes, PR interval 160 msec, QT interval 320 msec, there is ST-segment depression with T wave inversion seen in lead II, III, aVF, V5-V6, S wave height in V1 is 6 square boxes( 3 mv) and in V2 it is 9 squares boxes (4.5 mv), R wave height in lead V5 and V6 is 7 square boxes (3.5 mv) so, the sum of  S wave in lead V1 and V6 is 6.5 mv suggestive of concentric type of Left ventricular hypertrophy with left ventricular strain pattern. The patient underwent ECHO, which was suggestive of severe concentric left ventricular hypertrophy with grade 1 diastolic dysfunction.

Let's discuss ECG criteria for Left ventricular hypertrophy

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Praveen Gupta

WPW syndrome with atrial fibrillation

A 37 years old male came with the history of acute onset palpitation of two hours duration. Tachycardia ECG is shown below.

Tachycardia ECG (Click on the image to enlarge it)

ECG is showing broad QRS complex tachycardia, irregularly irregular @ 200 beats per minutes, No AV dissociation no fusion beats no capture beats seen, QRS is showing RBBB morphology in lead V1, variable QRS morphology, negative delta wave in lead II,III, avF,  Positive delta wave are seen in lead I, avL, V1 to V4 

ECG Diagnosis: Broad complex tachycardia, irregularly irregular suggestive

Differential diagnosis: Pre-excited tachycardia, Atrial fibrillation with underlying aberrancy.

Another tachycardia ECG of the patient

Another tachycardia ECG of the patient

Patient was given injection amiodarone but his tachycardia did not subside. DC cardioversion was done. Post cardioversion sinus ECG is shown below

Sinus ECG(Click on the image to enlarge it)

ECG is showing sinus rhythm @ 80 bpm, PR  60 msec, Left axis deviation, Negative delta wave seen in lead II, III, avF, Positive delta wave seen in lead V2-V5. Ecg is suggestive of WPW syndrome. As the delta wave is negative in lead 2, it is most likely pathway from coronary sinus diverticulum.
The patient underwent electrophysiological study which showed WPW syndrome with pathway originating from Coronary sinus diverticulum.

Lets discuss pathway localization for WPW syndrome.

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Praveen Gupta

Atrial flutter

A 64-year-old male came with a history of acute onset palpitation along with dyspnoea, orthopnea, and paroxysmal nocturnal dyspnoea. The patient was a known case of severe aortic valve stenosis with aortic valve regurgitation with moderate mitral regurgitation and was on medical follow up. ECG of the patient during tachycardia is shown below.

ECG is showing heart rate of 156 beats per minutes, narrow QRS complex, irregularly irregular, P wave is seen, RP interval is long then PR interval, there is ST segment depression in lead V4-V6, so the ECG is suggestive of  narrow QRS complex irregularly irregular, long RP tachycardia with visible P wave,  so the most likely differential diagnosis atrial tachycardia or atrial flutter with 1:1 AV conduction.

Another ECG Of the patient taken five minutes after first ECG

ECG is showing heart rate of 98 beats per minutes, irregularly irregular, there are P wave present which is of Sawtooth appearance, P wave is  positive in lead 2,3,avF, there is ST segment depression seen in lead I,II, III, V5,V6 so the ECG is suggestive of atrial flutter with variable block.

Lets discuss how to approach in a patient with narrow QRS complex tachycardia

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Praveen Gupta

Posterior wall myocardial infarction with inferior wall myocardial infarction

A 45 years old male came with the history of acute onset retrosternal chest pain of 3 hours duration. The patient was a chronic smoker. ECG is shown below

ECG 1

ECG is showing bradycardia with heart rate of 38 beats per minute, regular in nature, no clearly visible P wave seen, there is ST segment elevation in lead 2,3,avF with marked ST-segment depression in lead V1-V5, also in lead V6, there is prominent R wave seen in lead V2, V3 along with upright T wave seen in lead V2-V5.  ECG is suggestive of acute inferior wall myocardial infarction with posterior wall myocardial infarction with junctional bradycardia.

ECG 2

ECG is showing ST-segment elevation in lead 2,3,avF with marked ST-segment depression in lead V1-V4 also in lead V5, there is prominent R wave seen in lead V1- V4 suggestive of R/S ratio > 1 along with upright T wave in lead V2-V6, suggestive of posterior wall myocardial infarction. 

The patient was immediately started on streptokinase thrombolytic therapy. Post thrombolysis ECG is shown below.

 ECG 3 (Post thrombolysis)

 ECG after thrombolysis was still showing ST-segment elevation in lead 2,3,avF with ST-segment depression in lead V1-V5 suggestive of failed thrombolysis. The patient was immediately taken for Rescue PCI which was suggestive of Co-dominant coronary circulation with both RCA and LCX dominance with TIMI 3 flow so further intervention was deferred. The patient was started on medical therapy and planned for delayed Percutaneous intervention.

Little bit about 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.
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Praveen Gupta

Inferior wall myocardial infarction with variable block

A 55 years old male came with a history of acute onset chest pain of 2 hours duration along with giddiness. The patient was a known case of diabetes mellitus and hypertension. Patient ECG is shown below.

ECG 1

ECG is showing bradycardia @ 36 beats per minute,  AV dissociation, P wave @ 100bpm, ST- segment elevation in lead II, III, avF, ST-segment depression in  avL, V2-V6 

ECG diagnosis: Acute ST-elevation myocardial infarction with complete heart block.

Another ecg of the patient taken after ten minute

ECG is showing dissociation of P wave and QRS complex suggestive of complete heart block. There is ST- segment elevation in lead II, III,avF with ST-segment depression in lead I, avL, V2-V6 

Diagnosis: Acute ST-elevation inferior wall myocardial infarction with complete heart block.

The patient was immediately thrombolysed and there is the resolution of ST-elevation and complete heart block after thrombolysis.

Thank you

Praveen Gupta