Wednesday, April 13, 2011

Interesting ECG (7)

(Click to enlarge)
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I have this interesting ECG sent to me by a postgraduate Medical Registrar from Kenya and we would like to share this for discussion.
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What do you think it is?

10 comments:

stareternity said...

i can only recognise these points:
1. the heart rate is around 100beats/min.
2. this is a Right Axis Deviation.
3. QRS widened.
4. prolonged PR interval.
5. prolonged QT interval.
6. there is Inverted T-wave at Lead II & III.
7. there QRS in Chest Lead V5,V6 should be a positive wave, but this shows a negative wave.

i think might be Posterior Fascicular Block?

Darren Lee said...

Tough ECG?

To me I think it's a nonsustained Ventricular tachycardia, and the clue is that in the long lead II it's back to a narrow-complex sinus rhythm.

I've confirmed this with a cardiologist, he agrees and he added a few points:
This is a VT which it has LBBB pattern, and the right axis indicating the origin of the VT is from right chamber, possibly RV outflow tract or right basal. AV dissociation is also seen, supporting the diagnosis.

One more thing I noticed is that the rate of VT is not really fast as what's usually seen. I think this is probably what we call "Slow VT" in which the rate is <100-120pm and found in young adult sometimes. It is, however, usually benign and not treated unless associated with hemodynamic symptoms.

Thanks Faiz for sharing the ECG! ;)

Shay said...

Hi Dr Lee,

I just couldn't say this is a VT! Definitely miss it.

Could you please point out where do you see AV dissociation?

And can we consider idioventricular rhythm as one of the differetial ddx?

If VT is the case, is this patient taking any medication? How old is this patient?

Thanks.

Anonymous said...

Thanks Dr. Lee. A very interesting EKG indeed! Great explanation!!!

Zinj said...

Thanks Darren! That was a tough one!

Darren Lee said...

Anonymous & Zinj: Thanks! ;)

Shay: No this is not my patient..as I said, this ECG is sent to me by a registrar for discussion.

The cardiologist's opinion is that the PR of the broad-complex tachy is different from the PR of the sinus beat.

But I agree that the AV dissociation may not be very obvious. AIVR (accelerated idioventricular rhythm) is definitely a differential, and if you check, these 2 conditions (AIVR & Slow VT) actually overlap and some even consider they are the same! ;)

Anonymous said...

isn't it acute Q wave STEMI? i can see Q wave and ST elevation in almost all chest leads..n i don't see any signs of VT as QRS complex isn't broad...correct me if im wrong..TQ

Darren Lee said...

Anonymous:

I'd appreciate if you can leave a name ;)

I understand why you think it could be an acute Q wave MI, but in that case, it won't be back to a narrow-complex SR abruptly.
Take a look again ;)

Faceprints said...

Hi Darren, I am a final year medical student and I just came across your blog recently. It's well and truly marvelous, and I am inspired by the fact you still have a life outside of medicine!

I know months have passed since you posted this ECG, but I wanted to just ask whether it is possible that this is bidrectional ventricular tachycardia. A similar ECG can be found here:

http://hqmeded-ecg.blogspot.com/2011/08/southeast-asian-with-tachycardia-and.html

Darren Lee said...

Hi Faceprint,

Thanks and welcome here! ;)

The ECG that you refer to, is actually not entirely the same as in my case. If you look carefully, the ECG of bidirectional VT shows the QRS complexes of two different morphologies and it's alternating. By a quick look some may mistaken it as bigeminy PVCs.

The multifocal morphologies, however, is not seen in the ECG in my case. So they're actually not the same.

Feel free to discuss if you have further doubt. ;)

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