An Old Lady with Chest Pain: Difference between revisions

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m (New page: {{NHJ| |mainauthor= '''A.A.M. Wilde''' |edition= 2006:04,154 }} Figure 1|thumb A 90-year-old lady presented with chest pain which had a sudden onset i...)
 
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[[Puzzle_2006_4_154 Answer|Answer]]
[[Puzzle_2006_4_154 Answer|Answer]]
[[Image:Puzzle_2006_4_154_fig2.jpg|Figure 2|thumb]]
A careful look at the ECG reveals no clear P waves.
There is a bradycardic rhythm with initially a slight
irregularity in the QRS complexes. In the last part of
the ECG, QRS complexes follow each other on a
regular basis with 1440 ms intervals (see rhythm strip
at the bottom). The QRS width is 120 ms. The ST
segments are markedly deviated: ST elevation in lead
III and less evident in lead II and aVF and ST depression
in leads I, aVL, V1 and V3. In addition there
is ST elevation in lead aVR.
Based on these ECG changes, the diagnosis should
be atrial fibrillation and inferior-posterior myocardial
infarction. The slow heart rate suggests the presence
of advanced AV-nodal conduction block, a common
feature in the setting of inferior wall infarction. ST
elevation in lead aVR suggests that the right ventricle
is involved as well. A further indication of RV involvement
is the rightward displacement of the precordial
leads (i.e. the next step should be a rightward pooled
ECG; figure 2). This ECG shows clear ST elevation in
the right precodial leads and now a regular slow ventricular
rhythm, substantiating the diagnosis of advanced
AV nodal conduction block (i.e. total AV block in the
presence of atrial fibrillation). Acute coronary
angiography revealed an (anticipated) proximal right
coronary artery occlusion.
In both ECGs lead V2 is probably not at the correct
position, it is either at the position of V1 (and V1 at the
position of V2) or even more displaced to the right.

Revision as of 19:01, 8 October 2007

Author(s) A.A.M. Wilde
NHJ edition: 2006:04,154
These Rhythm Puzzles have been published in the Netherlands Heart Journal and are reproduced here under the prevailing creative commons license with permission from the publisher, Bohn Stafleu Van Loghum.
The ECG can be enlarged twice by clicking on the image and it's first enlargement
Figure 1

A 90-year-old lady presented with chest pain which had a sudden onset in the middle of the night. There were no other symptoms. She never had experienced similar pain before. There was no other relevant medical history. She was not on any medication. Physical examination revealed no abnormalities. The first ECG is shown in figure 1 (standard calibration).

What is your diagnosis and what would be the next step?

Answer

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