|
|
| Line 17: |
Line 17: |
|
| |
|
| [[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.
| |
