ECG Guru - Instructor Resources - Pathological Q waves https://www.ecgguru.com/ecg/pathological-q-waves en Onset of Pathological Q Waves https://www.ecgguru.com/ecg/onset-pathological-q-waves <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/onset-pathological-q-waves"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/ECG%201%20LAD%20Edit.jpg" width="1800" height="1034" alt="" /></a></div><div class="field-item odd"><a href="/ecg/onset-pathological-q-waves"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/ECG%202%20LAD%20Q%20Waves%20Edit.jpg" width="1800" height="982" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal">&nbsp;<strong><span style="color: #00b050;">The Patient:</span></strong><span style="color: #00b050;">&nbsp;&nbsp;&nbsp;&nbsp; </span>44-year-old man with chest pain.&nbsp; Symptoms started over 24 hours ago. The EMS crew recognized an acute M.I. on the ECG and transferred him immediately to a cardiac hospital. They started two I.V.s and gave aspirin enroute.&nbsp;</p><p class="MsoNormal">&nbsp;</p><p class="MsoNormal"><strong><span style="color: #00b050;">ECG No. 1 @17:43:<span style="mso-spacerun: yes;">&nbsp;&nbsp;&nbsp; </span></span>The rhythm </strong>is sinus tachycardia at 118 bpm.<span style="mso-spacerun: yes;">&nbsp; </span>The PR interval is within normal limits at 130 ms, and the QRS is narrow at 84 ms.<span style="mso-spacerun: yes;">&nbsp; </span>The QTCc is 478 ms by the machine’s measurement, but we measured the QT at 303 ms and QTc as 376-419 ms via various methods, which are within normal limits. The QRS frontal plane axis is at 15 degrees, within normal limits.</p><p class="MsoNormal"><strong>The ST segments</strong> are elevated and mostly straight in Leads V1 through V5, I and aVL. There is mild ST depression in III and aVF.<span style="mso-spacerun: yes;">&nbsp; </span>Very concerning are the pathological Q waves in V1 through V5, indicating loss (death) of myocardial tissue in the anterior wall.<span style="mso-spacerun: yes;">&nbsp; </span><strong></strong></p><p class="MsoNormal"><strong><span style="color: #00b050;">ECG No. 2 @ 17:53:<span style="mso-spacerun: yes;">&nbsp; </span></span></strong>The second ECG was performed about 10 minutes later, and V4, V5, and V6 were replaced by V7, V8, and V9.<span style="mso-spacerun: yes;">&nbsp; </span>Reciprocal ST depression is observed in those additional leads. The heart rate is now 128 bpm.<span style="mso-spacerun: yes;">&nbsp; </span>It is notable that pathological Q waves have now appeared in Leads I and aVL. There has been no change in lead placement.<span style="mso-spacerun: yes;">&nbsp; </span>The onset of necrosis in the high lateral wall has shifted the frontal plane axis toward the right extreme of normal, at 86 degrees, and now II, III, and aVF have prominent R waves. Another cause for right axis shift in anterior wall M.I. to consider would be posterior hemiblock. However, that is a diagnosis of exclusion, and the new Q waves explain the axis shift. <span style="mso-spacerun: yes;">&nbsp;</span>It is interesting that the <em>onset </em>of pathological Q waves was captured in these serial ECGs.</p><p class="MsoNormal"><strong><span style="color: #00b050;">Follow Up:<span style="mso-spacerun: yes;">&nbsp;&nbsp;&nbsp; </span></span></strong>The patient was found to have troponin levels over 40, and an occlusion of the left anterior descending artery. <span style="mso-spacerun: yes;">&nbsp;</span>In addition, he had severe multi-vessel disease.<span style="mso-spacerun: yes;">&nbsp; </span>Angioplasty was done on the LAD, with stent, and he was scheduled for 4-vessel coronary artery bypass surgery the following day.<span style="mso-spacerun: yes;">&nbsp; </span>He was maintained on a balloon pump in the CVICU awaiting surgery.</p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/301/feed" method="post" id="fivestar-custom-widget" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--2" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Onset of Pathological Q Waves 1/5</option><option value="40">Give Onset of Pathological Q Waves 2/5</option><option value="60">Give Onset of Pathological Q Waves 3/5</option><option value="80" selected="selected">Give Onset of Pathological Q Waves 4/5</option><option value="100">Give Onset of Pathological Q Waves 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.1</span></span> <span class="total-votes">(<span >12</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-fqIthpWnvYSl6w_9t7bywdnTIV51_kt9dbmHIMOU9Qc" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/pathological-q-waves" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Pathological Q waves</a></div><div class="field-item odd"><a href="/ecg/anterior-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Anterior M.I.</a></div><div class="field-item even"><a href="/ecg/anterior-lateral-mi-0" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Anterior-lateral M.I.</a></div><div class="field-item odd"><a href="/ecg/stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">STEMI</a></div><div class="field-item even"><a href="/ecg/st-elevation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST elevation</a></div><div class="field-item odd"><a href="/ecg/axis-shift" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Axis shift</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_1"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fonset-pathological-q-waves&amp;title=Onset%20of%20Pathological%20Q%20Waves"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> <script type="text/javascript"> <!--//--><![CDATA[//><!-- if(window.da2a)da2a.script_load(); //--><!]]> </script></span></li> </ul> Fri, 17 Jul 2020 16:44:22 +0000 Dawn 787 at https://www.ecgguru.com https://www.ecgguru.com/ecg/onset-pathological-q-waves#comments Previous Anterior Wall M.I. https://www.ecgguru.com/ecg/previous-anterior-wall-mi <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/previous-anterior-wall-mi"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/AVB119%20First%20deg%20AVB%20old%20AWMI.jpg" width="1800" height="1274" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal">&nbsp;</p><p class="MsoNormal">If you are an instructor, or a fairly new student, you don’t always need to see “challenging” ECGs. But, you may not want to see “standard” ECGs from an arrhythmia generator, either.<span style="mso-spacerun: yes;">&nbsp; </span>Every ECG contains subtle and not, so subtle characteristics of the person it belongs to.<span style="mso-spacerun: yes;">&nbsp; </span>Take a minute to look at this ECG before reading the discussion, and ask yourself what you might surmise about the patient.</p><p class="MsoNormal"><strong><span style="color: #00b050;">The Patient: </span></strong>We don’t know much about the actual patient this ECG came from.<span style="mso-spacerun: yes;">&nbsp; </span>What we do know is that he is an elderly man with a history of heart disease who was hospitalized sometime in the past with an acute M.I.<span style="mso-spacerun: yes;">&nbsp; </span>He is now on beta blocker medication and is on a diet, as he is approaching the “morbidly obese” classification.<span style="mso-spacerun: yes;">&nbsp; </span>He is now in the ER with shortness of breath and mild chest pain.<span style="mso-spacerun: yes;">&nbsp; </span>What does his ECG tell us?</p><p class="MsoNormal"><strong><span style="color: #00b050;">The ECG:<span style="mso-spacerun: yes;">&nbsp; </span><span style="mso-spacerun: yes;">&nbsp;</span><span style="mso-spacerun: yes;">&nbsp;</span><span style="mso-spacerun: yes;">&nbsp;</span></span></strong>The <strong>rhythm is sinus</strong> at a rate of 60 bpm.<span style="mso-spacerun: yes;">&nbsp; </span>Not quite “sinus brady”. His PR interval is 273 ms, or .27 seconds: <strong>first-degree AV block</strong>.<span style="mso-spacerun: yes;">&nbsp; </span>Both of these findings can be attributed to the beta blocker, which slows the heart rate and slows conduction through the AV node. <span style="mso-spacerun: yes;">&nbsp;</span>His <strong>QRS is slightly widened</strong>, at 106 ms, or .11 seconds. Not wide enough for a diagnosis of bundle branch block, but indicative of some delay through the interventricular conduction system.<span style="mso-spacerun: yes;">&nbsp; </span>This could be due to multiple causes, including, but not limited to, his medication or his previous M.I.<span style="mso-spacerun: yes;">&nbsp; </span>The <strong>QRS axis is -16 degrees,</strong> or very slightly to the left, which is normal.<span style="mso-spacerun: yes;">&nbsp; </span>The<strong> R wave progression</strong> in the chest leads is appropriately from negative in V1 to positive in V6.<span style="mso-spacerun: yes;">&nbsp; </span>However, he has lost the usual “RS” pattern in V2 and V3. The normal small “r” waves have gone, leaving <strong>pathological Q waves</strong>, a sign of the permanent damage done by his previous anterior-septal wall M.I.<span style="mso-spacerun: yes;">&nbsp; </span>There is <strong>no ST elevation or depression</strong>, and his <strong>T waves are upright</strong> except in aVR, a normal finding.<span style="mso-spacerun: yes;">&nbsp; </span>A perfectionist might not find the shapes of all of the ST segments to be perfect, but he does have coronary artery disease and advanced age.<span style="mso-spacerun: yes;">&nbsp; </span>His <strong>QTc is within normal limits</strong>. <span style="mso-spacerun: yes;">&nbsp;</span>The <strong>voltage in almost all leads is low</strong>. When not localized to one area, this can be a sign of excess tissue in between the heart and the ECG electrodes, which this man did have.<span style="mso-spacerun: yes;">&nbsp; </span></p><p class="MsoNormal">While the ECG does not tell us everything we need to know about this patient, it is able to point us in the direction of what questions to ask and what other tests to do.<span style="mso-spacerun: yes;">&nbsp; </span>And it shows us a rate and rhythm that do not require immediate intervention.</p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/301/feed" method="post" id="fivestar-custom-widget--2" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--4" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Previous Anterior Wall M.I. 1/5</option><option value="40">Give Previous Anterior Wall M.I. 2/5</option><option value="60">Give Previous Anterior Wall M.I. 3/5</option><option value="80" selected="selected">Give Previous Anterior Wall M.I. 4/5</option><option value="100">Give Previous Anterior Wall M.I. 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.2</span></span> <span class="total-votes">(<span >157</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--2" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-EtORla0qo1kZlX1k5yxuRet3BJlzdnaqFqcIftDSWrY" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/first-degree-av-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">First-degree AV block</a></div><div class="field-item odd"><a href="/ecg/pathological-q-waves" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Pathological Q waves</a></div><div class="field-item even"><a href="/ecg/anterior-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Anterior M.I.</a></div><div class="field-item odd"><a href="/ecg/anterior-septal-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Anterior-septal M.I.</a></div><div class="field-item even"><a href="/ecg/awmi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">AWMI</a></div><div class="field-item odd"><a href="/ecg/low-voltage-qrs" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Low voltage QRS</a></div><div class="field-item even"><a href="/ecg/previous-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Previous M.I.</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_2"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fprevious-anterior-wall-mi&amp;title=Previous%20Anterior%20Wall%20M.I."><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Sun, 08 Mar 2020 02:52:42 +0000 Dawn 782 at https://www.ecgguru.com https://www.ecgguru.com/ecg/previous-anterior-wall-mi#comments Right Bundle Branch Block With Probable Previous M.I. https://www.ecgguru.com/ecg/right-bundle-branch-block-probable-previous-mi <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/right-bundle-branch-block-probable-previous-mi"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/RBLAH104.jpg" width="1800" height="1347" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal"><strong><span style="color: #00b050;">This ECG </span></strong>was obtained from an 87-year-old man with chest discomfort.&nbsp; We have no other clinical information.</p><p class="MsoNormal"><strong><span style="color: #00b050;">ECG Interpretation&nbsp;&nbsp; </span></strong>The rhythm is regular and fast, with P waves, at 95 beats per minute. So, it is <strong>normal sinus rhythm</strong>, but the rate is probably not “normal” for this patient. &nbsp;The P waves are small, and difficult to see.&nbsp; We suggest Lead I to best view the P waves in this example. This is a good opportunity to teach the value of evaluating rhythm strips in more than one simultaneous lead, as subtle features may not show up well in all leads.&nbsp; There is a <strong>first-degree AV block</strong>, with a PR interval of 232 ms.</p><p class="MsoNormal">We see the <strong>right bundle branch block (RBBB) pattern</strong>: rSR’ in the right precordial leads (with a tiny q wave in V1, which is not typical of &nbsp;RBBB).&nbsp; The QRS is wide at 148 ms (.148 seconds).&nbsp; The R prime (R’) represents the right ventricle depolarizing slightly after the left ventricle.&nbsp; This terminal delay widens the QRS without affecting the depolarization or contraction of the left ventricle.&nbsp; This delay can be seen in every lead, but is especially easy to see in Leads I and V<sub>6</sub>, where there is a wide little s wave.&nbsp; It is normal for the T waves to be in a direction opposite that of the terminal wave (inverted in Leads V<sub>1</sub> and III, for example.)</p><p class="MsoNormal"><strong>There is left axis deviation.</strong>&nbsp; The causes of LAD are many.&nbsp; It is not unusual for people with RBBB to also have a left anterior hemiblock (LAH), also called left anterior fascicular block.&nbsp; The left anterior fascicle has the same blood supply as the right bundle branch.&nbsp; &nbsp;LAH causes a frontal plane axis shift – instead of Lead II having the tallest QRS of the limb leads, Leads I and aVL will be the tallest upright QRS complexes of the six limb leads.&nbsp; Lead II will be very small, or flat, or negative. However, the probability of <strong>pathological Q waves</strong> in the inferior leads offers a more likely explanation for the leftward axis shift.&nbsp; The M.I. that would have caused these Q waves is old, as there are no acute ST changes.&nbsp; It would, of course, help to know this patient’s history.</p><p class="MsoNormal">Right bundle branch block can make evaluating for ST segment elevation a bit tricky.&nbsp; Occasionally, the terminal delay – especially in Leads III and aVF – can be mistaken for ST elevation.&nbsp; The J points in this ECG all appear to be at the baseline, with no overt STEMI.</p><p class="MsoNormal">&nbsp;</p><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;"><span style="color: #00b050;"><span style="color: #000000; font-size: 13.008px; font-weight: normal;">Unfortunately, we do not have information about the patient’s diagnosis or outcome.</span></span></strong></p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/301/feed" method="post" id="fivestar-custom-widget--3" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--6" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Right Bundle Branch Block With Probable Previous M.I. 1/5</option><option value="40">Give Right Bundle Branch Block With Probable Previous M.I. 2/5</option><option value="60">Give Right Bundle Branch Block With Probable Previous M.I. 3/5</option><option value="80">Give Right Bundle Branch Block With Probable Previous M.I. 4/5</option><option value="100">Give Right Bundle Branch Block With Probable Previous M.I. 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="empty">No votes yet</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--3" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-wjOKnEr-fCZrZS0SljqKw-c6ByXRUZ7j1Xvq8J2dcQQ" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/right-bundle-branch-block-1" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Right bundle branch block</a></div><div class="field-item odd"><a href="/ecg/rbbb" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">RBBB</a></div><div class="field-item even"><a href="/ecg/pathological-q-waves" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Pathological Q waves</a></div><div class="field-item odd"><a href="/ecg/first-degree-av-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">First-degree AV block</a></div><div class="field-item even"><a href="/ecg/previous-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Previous M.I.</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_3"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fright-bundle-branch-block-probable-previous-mi&amp;title=Right%20Bundle%20Branch%20Block%20With%20Probable%20Previous%20M.I."><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Sat, 08 Sep 2018 20:35:12 +0000 Dawn 760 at https://www.ecgguru.com https://www.ecgguru.com/ecg/right-bundle-branch-block-probable-previous-mi#comments Anterior Wall M.I. With Ventricular Bigeminy https://www.ecgguru.com/ecg/anterior-wall-mi-ventricular-bigeminy <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/anterior-wall-mi-ventricular-bigeminy"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/AW126.jpg" width="1800" height="992" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;"><span style="color: #00b050;">The Patient</span></strong><span style="color: #00b050;"><span style="mso-spacerun: yes;">&nbsp;&nbsp;&nbsp;&nbsp; </span></span>This ECG was obtained from a 51-year-old man who presented to EMS with acute chest pain. He had a history of hypertension, 40 pack-year smoker.</p><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;"><span style="color: #00b050;">Hospital Course</span></strong><span style="color: #00b050;"><span style="mso-spacerun: yes;">&nbsp;&nbsp;&nbsp;&nbsp; </span></span>He was diagnosed with anterior wall STEMI and taken to the cath lab.<span style="mso-spacerun: yes;">&nbsp; </span>He was rated Killips Class 1 (no evidence of congestive heart failure), <a href="http://circ.ahajournals.org/content/102/17/2031">TIMI risk score 4</a><span style="mso-spacerun: yes;">&nbsp; </span>(14% risk of all-cause 30-day mortality).<span style="mso-spacerun: yes;">&nbsp; </span>He underwent primary percutaneous coronary intervention (PCI) of the proximal left anterior descending coronary artery (LAD).</p><p class="MsoNormal">Ten days post PCI, the patient had ventricular arrhythmias and went into cardiac arrest, but was resuscitated. He continued to have occurrences of non-sustained ventricular tachycardia (VT), progressing to sustained VT.<span style="mso-spacerun: yes;">&nbsp; </span>Electrolytes were monitored and corrected when necessary. The patient expired before any further diagnosis was made.</p><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;"><span style="color: #00b050;">ECG Interpretation<span style="mso-spacerun: yes;">&nbsp;&nbsp;&nbsp; </span></span>The rhythm</strong> is sinus at a rate of about 80 bpm (first two beats).<span style="mso-spacerun: yes;">&nbsp; </span>The PR interval is about .18 seconds.<span style="mso-spacerun: yes;">&nbsp; </span>The QRS duration is about .10 seconds.<span style="mso-spacerun: yes;">&nbsp; </span>After the second sinus beat, ventricular bigeminy occurs. Every other sinus beat is obscured by the PVCs. <span style="mso-spacerun: yes;">&nbsp;</span>By the end of the strip, the underlying sinus rhythm has slowed slightly.</p><p class="MsoNormal">The ECG signs that the <strong style="mso-bidi-font-weight: normal;">ectopic beats</strong> are ventricular are:<span style="mso-spacerun: yes;">&nbsp; </span>lack of P waves associated with the premature beats, QRS width about .16 seconds, and compensatory pauses.<span style="mso-spacerun: yes;">&nbsp; </span>The axis of the sinus beats is around 60 degrees (normal), but the axis of the premature beats is difficult to determine due to the low voltage and biphasic QRS complexes in the frontal plane leads.<span style="mso-spacerun: yes;">&nbsp; </span>It is also difficult to determine ST and T wave changes in the PVCs for the same reason.</p><p class="MsoNormal">Leads V<sub>1</sub> through V<sub>4 </sub>have well-developed pathological <strong style="mso-bidi-font-weight: normal;">Q waves</strong> (a sign of necrosis and usually permanent damage).<span style="mso-spacerun: yes;">&nbsp; </span>The ST segments are flat in Leads V<sub>5</sub> and V<sub>6</sub>, as well as in all the limb leads.<span style="mso-spacerun: yes;">&nbsp; </span><strong style="mso-bidi-font-weight: normal;">The ST</strong> <strong style="mso-bidi-font-weight: normal;">segments are elevated</strong> in V<sub>1</sub> through V<sub>3</sub>, and possibly in V4 (difficult to measure due to artifact).<span style="mso-spacerun: yes;">&nbsp; </span>We do not have information about how long after the acute STEMI this ECG was obtained.</p><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;"><span style="color: #00b050;">Additional Considerations<span style="mso-spacerun: yes;">&nbsp; </span></span></strong>Sadly, this relatively young patient did not survive.<span style="mso-spacerun: yes;">&nbsp; </span>There is always a possibility of mortality after myocardial infarction, even though chance of survival has improved greatly in recent years.<span style="mso-spacerun: yes;">&nbsp; </span>One consideration in any patient who has persistent ST elevation after STEMI is <strong style="mso-bidi-font-weight: normal;">ventricular aneurysm</strong>.<span style="mso-spacerun: yes;">&nbsp; </span>It is presumed this patient was evaluated for that condition (we do not have complete information).<span style="mso-spacerun: yes;">&nbsp; </span>ECG signs of ventricular aneurysm include:</p><p class="MsoNormal" style="margin-bottom: .0001pt; line-height: normal;">*<span style="mso-spacerun: yes;">&nbsp;&nbsp;&nbsp;&nbsp; </span>ST elevation that persists beyond two weeks after acute M.I. (commonly in anterior leads).</p><p class="MsoNormal" style="margin-bottom: .0001pt; line-height: normal;">*<span style="mso-spacerun: yes;">&nbsp;&nbsp;&nbsp;&nbsp; </span>Often associated with well-formed Q waves, or QS pattern.</p><p class="MsoNormal" style="margin-bottom: .0001pt; line-height: normal;">*<span style="mso-spacerun: yes;">&nbsp;&nbsp;&nbsp;&nbsp; </span>Small-amplitude T waves.</p><p class="MsoNormal" style="margin-bottom: .0001pt; line-height: normal;">*&nbsp; &nbsp; &nbsp;Absence of reciprocal ST depression.</p><p class="MsoNormal" style="margin-bottom: .0001pt; line-height: normal;">LV aneurysms can spontaneously rupture, causing almost instant death.<span style="mso-spacerun: yes;">&nbsp; </span>Also, scar tissue is arrhythmogenic.<span style="mso-spacerun: yes;">&nbsp; </span>The pathological Q waves on this ECG indicate scar tissue has formed. This can be the cause of the persistent PVCs and ventricular tachycardia.<span style="mso-spacerun: yes;">&nbsp; </span>Damage to the left ventricle can also lead to congestive heart failure, with or without LV aneurysm. Mural thrombi can form at the site of the STEMI and embolize.</p><p class="MsoNormal" style="margin-bottom: .0001pt; line-height: normal;">&nbsp;</p><p class="MsoNormal" style="margin-bottom: .0001pt; line-height: normal;"><em style="mso-bidi-font-style: normal;">Our thanks to Adam Cortz for donating this ECG.</em></p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/301/feed" method="post" id="fivestar-custom-widget--4" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--8" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Anterior Wall M.I. With Ventricular Bigeminy 1/5</option><option value="40">Give Anterior Wall M.I. With Ventricular Bigeminy 2/5</option><option value="60">Give Anterior Wall M.I. With Ventricular Bigeminy 3/5</option><option value="80">Give Anterior Wall M.I. With Ventricular Bigeminy 4/5</option><option value="100" selected="selected">Give Anterior Wall M.I. With Ventricular Bigeminy 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4.3</span></span> <span class="total-votes">(<span >4</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--4" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-e56wGqFs5NR9wkO27YFJajcAlgwEdAyZvyzfIkYu5Hc" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/anterior-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Anterior M.I.</a></div><div class="field-item odd"><a href="/ecg/ventricular-bigeminy" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Ventricular bigeminy</a></div><div class="field-item even"><a href="/ecg/pathological-q-waves" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Pathological Q waves</a></div><div class="field-item odd"><a href="/ecg/st-elevation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST elevation</a></div><div class="field-item even"><a href="/ecg/stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">STEMI</a></div><div class="field-item odd"><a href="/ecg/ventricular-aneurysm" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Ventricular aneurysm</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_4"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fanterior-wall-mi-ventricular-bigeminy&amp;title=Anterior%20Wall%20M.I.%20With%20Ventricular%20Bigeminy"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Sat, 21 Jul 2018 23:29:19 +0000 Dawn 759 at https://www.ecgguru.com https://www.ecgguru.com/ecg/anterior-wall-mi-ventricular-bigeminy#comments Recent M.I. https://www.ecgguru.com/ecg/recent-mi-0 <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/recent-mi-0"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/AW%20122%20MI%201%20wk%20ago.jpg" width="3184" height="2006" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal">This ECG is from a 54-year-old woman who had an M.I. one week prior to this tracing.&nbsp; She did not receive interventional treatment, as it was not available where she lived when this happened years ago. &nbsp;Her ECG shows the signs of healing injury, as well as probable permanent damage.<span style="font-size: 13.008px; line-height: 1.538em;">&nbsp;</span></p><p class="MsoNormal"><strong><span style="color: #2f5597; mso-themecolor: accent5; mso-themeshade: 191; mso-style-textfill-fill-color: #2F5597; mso-style-textfill-fill-themecolor: accent5; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-colortransforms: lumm=75000;">Where was this M.I.?</span></strong><span style="color: #2f5597; mso-themecolor: accent5; mso-themeshade: 191; mso-style-textfill-fill-color: #2F5597; mso-style-textfill-fill-themecolor: accent5; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-colortransforms: lumm=75000;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>The affected leads are all of the precordial leads (V1 through V6), as well as I and aVL.&nbsp;&nbsp; The precordial leads reflect the anterior and low lateral walls of the heart, and Leads I and aVL show us the high lateral wall.&nbsp; This area is perfused by the left coronary artery, and she had a proximal lesion.<strong style="font-size: 13.008px; line-height: 1.538em;"><span style="font-size: 8.0pt; line-height: 107%; color: #2f5597; mso-themecolor: accent5; mso-themeshade: 191; mso-style-textfill-fill-color: #2F5597; mso-style-textfill-fill-themecolor: accent5; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-colortransforms: lumm=75000;">&nbsp;</span></strong></p><p class="MsoNormal"><strong><span style="color: #2f5597; mso-themecolor: accent5; mso-themeshade: 191; mso-style-textfill-fill-color: #2F5597; mso-style-textfill-fill-themecolor: accent5; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-colortransforms: lumm=75000;">What ST and T wave changes are present?&nbsp;&nbsp;&nbsp; </span></strong>All of the leads listed above show a flattening of the ST segments.&nbsp; While they are no longer elevated (the acute injury is over), they are flat and almost convex upward.&nbsp; This shape is usually abnormal, and it has persisted even though the acute injury is subsiding.&nbsp; The T waves in the anterolateral leads are all inverted.&nbsp; This represents reperfusion of the injured tissue.&nbsp; Whether the offending clot is removed by invasive procedure, thrombolytic drugs, or natural degradation, the tissue that is still alive will reperfuse.<span style="font-size: 8pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal"><strong><span style="color: #2f5597; mso-themecolor: accent5; mso-themeshade: 191; mso-style-textfill-fill-color: #2F5597; mso-style-textfill-fill-themecolor: accent5; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-colortransforms: lumm=75000;">What else is abnormal?</span></strong><span style="color: #2f5597; mso-themecolor: accent5; mso-themeshade: 191; mso-style-textfill-fill-color: #2F5597; mso-style-textfill-fill-themecolor: accent5; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-colortransforms: lumm=75000;">&nbsp;&nbsp;&nbsp;&nbsp; </span>There are pathological Q waves in V1, V2, and V3, or we could say, "loss of normal r waves". &nbsp;Typically,&nbsp;<span style="line-height: 1.538em;">precordial leads begin with an R wave.&nbsp; Lead V1 often has a small r wave, and the size of the R waves progresses across the chest until V6 is almost entirely upright. &nbsp;This is termed "R wave progression". Loss of the initial R wave in the right-sided chest leads is not always indicative of a "pathological Q wave". Also, a small "septal" q wave can sometimes be seen in V5 and V6. &nbsp;True pathological Q waves represent permanently damaged, necrotic myocardium. Poor R wave progression can be a result of pathological Q waves, or other conditions, including incorrect electrode placement. &nbsp;In this ECG, there appears to be a pathological Q wave in Lead III, as well, but isolated Q waves are not uncommon in Lead III, and this patient's current problem is a resolving anterolateral M.I. &nbsp;We don’t know this patient’s clinical status, but we do know that she was still hospitalized, and in the intensive cardiac care unit.</span><span style="font-size: 8pt; line-height: 107%;">&nbsp;</span></p><p class="MsoNormal"><strong><span style="color: #2f5597; mso-themecolor: accent5; mso-themeshade: 191; mso-style-textfill-fill-color: #2F5597; mso-style-textfill-fill-themecolor: accent5; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-colortransforms: lumm=75000;">Is there any good news?</span></strong><span style="color: #2f5597; mso-themecolor: accent5; mso-themeshade: 191; mso-style-textfill-fill-color: #2F5597; mso-style-textfill-fill-themecolor: accent5; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-colortransforms: lumm=75000;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>Well, this patient has survived a large and dangerous event so far.&nbsp; She is in normal sinus rhythm with a narrow QRS complex and normal intervals.</p><p class="MsoNormal">For a review of the coronary arteries’ distribution, please see the <a href="http://ecgguru.com/heart-illustrations/coronary-arteries-anterior-view-labeled">coronary arteries</a> illustration in Heart Art.</p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/301/feed" method="post" id="fivestar-custom-widget--5" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--10" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Recent M.I. 1/5</option><option value="40">Give Recent M.I. 2/5</option><option value="60">Give Recent M.I. 3/5</option><option value="80">Give Recent M.I. 4/5</option><option value="100" selected="selected">Give Recent M.I. 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4.8</span></span> <span class="total-votes">(<span >4</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--5" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-Aw5f_Jk6NjOj5iDHmBTgwUb-qnZNCShi3WauXnMx1AQ" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/anterior-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Anterior M.I.</a></div><div class="field-item odd"><a href="/ecg/t-wave-inversion" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">T Wave Inversion</a></div><div class="field-item even"><a href="/ecg/pathological-q-waves" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Pathological Q waves</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_5"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Frecent-mi-0&amp;title=Recent%20M.I."><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Thu, 21 Apr 2016 05:07:03 +0000 Dawn 695 at https://www.ecgguru.com https://www.ecgguru.com/ecg/recent-mi-0#comments Inverted T waves in Lateral Wall https://www.ecgguru.com/ecg/inverted-t-waves-lateral-wall <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/inverted-t-waves-lateral-wall"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/CAD108.jpg" width="1800" height="1317" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p>This ECG was obtained from a 49-year-old man who was a patient in an Emergency Dept. &nbsp;We do not know his presenting complaint, only that he had a history of insulin-dependent diabetes mellitus (IDDM). &nbsp;It was noted by the donor of the ECG that the patient had no chest pain, no shortness of breath, and no other cardiac symptoms. &nbsp;We do not know his hydration or electrolyte status. &nbsp;There are quite a few interesting abnormalities on this ECG, and the exact interpretation would, of course, depend upon the patient's clinical status. &nbsp;It would definitely help to be there!</p> <p>First, we note a sinus tachycardia at a rate of 118 bpm. &nbsp;This could be due to very many causes, including but not limited to: &nbsp;dehydration, pain, anxiety, high or low blood glucose, fever, or CHF. &nbsp;The PR and QT intervals are within normal limits. &nbsp;The QRS complexes are narrow. &nbsp;The axis is normal at 0 degrees. &nbsp;The QRS voltage in the lateral leads is on the high side of normal, but we do not know this patient's body type. &nbsp;Voltage as read by the ECG can be influenced by a thin chest (making voltage look larger) or a large chest (making voltage lower).</p> <p>There are T wave abnormalities in the lateral leads: &nbsp;I, aVL, V5 and V6. &nbsp;The T waves are inverted, which can have many meanings. &nbsp;However, when inverted T waves are in the lateral leads, as opposed to the inferior or right chest leads, it is often a sign of ischemia. &nbsp;The flat, horizontal ST segments can also signify coronary artery disease (CAD). &nbsp;This patient denied cardiac symptoms, but his age and history of IDDM make it probably that CAD is a factor. &nbsp;The leads with T wave inversion also have a small amount of ST segment depression. &nbsp;The right precordial leads, V1 and V2, have a small amount of ST elevation, &nbsp;This possibly represents a reciprocal change to the ST depression in V5 and V6.</p> <p>Because we are not at the bedside of this patient, there are many details we do not know. &nbsp;But these inverted T waves could be ischemic T waves, and this requires that the patient be further evaluated.</p> <p>As always, we welcome comments, as this ECG probably has more to say!</p> <p>&nbsp;</p> <p>REFERENCES: &nbsp;<a href="http://ecg-interpretation.blogspot.com/2012/07/ecg-interpretation-review-47-normal.html">Dr. Ken Grauer</a>, &nbsp;<a title="LITFL T waves" href="http://lifeinthefastlane.com/ecg-library/basic/t-wave/">Life In The Fast Lane</a>, <a title="World J Cardiology" href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC43225305/#__ffn_sectitle">World Journal of Cardiology</a>&nbsp;</p> </div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/301/feed" method="post" id="fivestar-custom-widget--6" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--12" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Inverted T waves in Lateral Wall 1/5</option><option value="40">Give Inverted T waves in Lateral Wall 2/5</option><option value="60">Give Inverted T waves in Lateral Wall 3/5</option><option value="80" selected="selected">Give Inverted T waves in Lateral Wall 4/5</option><option value="100">Give Inverted T waves in Lateral Wall 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4</span></span> <span class="total-votes">(<span >4</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--6" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-7eaCPRUwiJluLFrcKs3WcG5azcsfZbETZ9G_B36D-Cg" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/t-wave-inversion" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">T Wave Inversion</a></div><div class="field-item odd"><a href="/ecg/ischemia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Ischemia</a></div><div class="field-item even"><a href="/ecg/sinus-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus tachycardia</a></div><div class="field-item odd"><a href="/ecg/pathological-q-waves" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Pathological Q waves</a></div><div class="field-item even"><a href="/ecg/bi-atrial-enlargement" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Bi-atrial enlargement</a></div><div class="field-item odd"><a href="/ecg/left-ventricular-hypertrophy" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left ventricular hypertrophy</a></div><div class="field-item even"><a href="/ecg/strain-pattern" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Strain pattern</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_6"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Finverted-t-waves-lateral-wall&amp;title=Inverted%20T%20waves%20in%20Lateral%20Wall"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Wed, 11 Nov 2015 02:45:52 +0000 Dawn 676 at https://www.ecgguru.com https://www.ecgguru.com/ecg/inverted-t-waves-lateral-wall#comments Extensive Anterior Wall M.I. With Recent Inferior Wall M.I. https://www.ecgguru.com/ecg/extensive-anterior-wall-mi-recent-inferior-wall-mi <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/extensive-anterior-wall-mi-recent-inferior-wall-mi"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/AW103A%2B_1.png" width="1800" height="1349" alt="" /></a></div><div class="field-item odd"><a href="/ecg/extensive-anterior-wall-mi-recent-inferior-wall-mi"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/corc%20100%25%20lad%20branch13_%2828%29.jpg" width="512" height="512" alt="" /></a></div><div class="field-item even"><a href="/ecg/extensive-anterior-wall-mi-recent-inferior-wall-mi"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/AW103%20%20rca%20nearly%20100%251_%2823%29.jpg" width="512" height="512" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p>This 88-year-old woman was brought to the Emergency Department in cardiogenic shock. &nbsp;Very little is known of her past medical history, but it was relayed to the EMS responders that she had been ill for about four days, when she became much worse.</p><p>This ECG shows a large, acute anterio-lateral wall M.I., as evidenced by the ST ELEVATIONS in V2 through V6, Leads I and aVL. &nbsp;To make matters worse, there are PATHOLOGICAL Q WAVES in Leads V2 through V6. &nbsp;Pathological Q waves indicate areas of necrosis. &nbsp;Because the myocardium facing the positive electrode is not electrically active, we "see through" the dead tissue to the myocardium on the opposite side of the heart. &nbsp;Pathological Q waves could be thought of as "reciprocal R waves". &nbsp;This represents a great deal of dead myocardium, which will be akinetic - not moving.</p><p>To make matters worse, she has pathological Q waves in the INFERIOR WALL as well, in Leads II, III, and aVF. &nbsp;Her ST segments in those leads are flattened and possibly slightly elevated, but not much. &nbsp;There are no reciprocal ST depressions in I and aVL, because they are affected by the anterior - lateral wall M.I., and are elevated.</p><p>The accompanying photos show her left coronary artery angiogram indicating severe coronary artery disease and a "missing" left anterior descending artery. &nbsp;This is due to a proximal lesion that occurred around the area of the first diagonal artery, cutting off blood flow to a very large part of her anterior-lateral wall. &nbsp;The photo of the right coronary artery shows a very tight lesion which is allowing some blood to pass. &nbsp;The Interventionalist felt that this represented a resolving 100% occlusion (remember, she had been sick for four days). &nbsp;As the blood clot broke up, blood flowed again, lowering the ST segments. &nbsp;Unfortunately, permanent damage had already been done, and she had Q waves in the inferior wall also. &nbsp;This leaves very little of her heart beating, and it is easy to understand why she presented in shock. &nbsp;She suffered cardiac arrests several times during the procedure, and was managed with a balloon pump and ventilator.</p><p>Unfortunately, this type of injury is not survivable, and she died in the CVICU a few hours after her procedure. She contributes to our education by demonstrating the cumulative effects of M.I., especially when permanent damage occurs. &nbsp;For a look at her ventriculogram, to understand the devastating effects of these injuries, go to our <a title="Ventriculogram: Poor EF Massive MI" href="https://www.youtube.com/watch?v=tzXwJuGeYvE&amp;edit=vd">You Tube</a> channel.</p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/301/feed" method="post" id="fivestar-custom-widget--7" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--14" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Extensive Anterior Wall M.I. With Recent Inferior Wall M.I. 1/5</option><option value="40">Give Extensive Anterior Wall M.I. With Recent Inferior Wall M.I. 2/5</option><option value="60">Give Extensive Anterior Wall M.I. With Recent Inferior Wall M.I. 3/5</option><option value="80">Give Extensive Anterior Wall M.I. With Recent Inferior Wall M.I. 4/5</option><option value="100" selected="selected">Give Extensive Anterior Wall M.I. With Recent Inferior Wall M.I. 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4.9</span></span> <span class="total-votes">(<span >8</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--7" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-YqCHgmvm9xbpl_aifcSH-LbMdKeBh2UKkXLJBEPCSy4" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/anterior-wall-mi-5" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Anterior wall M.I.</a></div><div class="field-item odd"><a href="/ecg/inferior-wall-mi-0" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Inferior Wall M.I.</a></div><div class="field-item even"><a href="/ecg/cardiogenic-shock" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Cardiogenic shock</a></div><div class="field-item odd"><a href="/ecg/pathological-q-waves" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Pathological Q waves</a></div><div class="field-item even"><a href="/ecg/angiogram" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Angiogram</a></div><div class="field-item odd"><a href="/ecg/stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">STEMI</a></div><div class="field-item even"><a href="/ecg/st-elevation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST elevation</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_7"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fextensive-anterior-wall-mi-recent-inferior-wall-mi&amp;title=Extensive%20Anterior%20Wall%20M.I.%20With%20Recent%20Inferior%20Wall%20M.I."><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Fri, 29 Aug 2014 23:15:40 +0000 Dawn 594 at https://www.ecgguru.com https://www.ecgguru.com/ecg/extensive-anterior-wall-mi-recent-inferior-wall-mi#comments Acute Anterior-Lateral Wall M.I. https://www.ecgguru.com/ecg/acute-anterior-lateral-wall-mi <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/acute-anterior-lateral-wall-mi"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/AW120%20%20ON%20Site.jpg" width="1800" height="509" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p>This week's ECG is from a 47-year-old man who experienced a sudden onset of chest pain while mowing his lawn. &nbsp;He went on to suffer a cardiac arrest and was resuscitated. &nbsp;We do not have long-term followup on his outcome.</p><p>The experienced person will have no difficulty identifying a large acute antero-lateral wall M.I. &nbsp;There are massive <strong>ST segment elevations in Leads V1 through V6,</strong> reflecting acute injury from the septal side of the anterior wall (patient's right) to the anterior-lateral wall (patient's left). &nbsp;There are also<strong> ST elevations in Leads I and aVL</strong>, reflecting the high lateral wall. &nbsp;This indicates, and was confirmed in the cath lab, that the lesion is proximal - at or above the bifurcation of the left anterior descending artery and the circumflex artery. &nbsp;The ST depressions in the inferior wall leads (II, III, and aVF) likely represent reciprocal changes. &nbsp;You will note that the ST depression in Lead III has a very similar shape to the ST elevation in Lead aVL.</p><p>More bad news for this patient is the presence of&nbsp;<strong>pathological Q waves&nbsp;</strong>in Leads V1 through V4, reflecting transmural death of the myocardial tissue. &nbsp;This causes akinesis and poor left ventricular function. &nbsp;In addition, it's not only muscle tissue that dies, but also electrical structures , such as bundle branches. &nbsp; Papillary muscles can be infarcted, causing valve malfunction. &nbsp;And remember, all patients who have ST elevation due to acute injury are vulnerable to ventricular tachycardia and ventricular fibrillation, due to re-entry mechanisms in injured tissue. &nbsp;&nbsp;</p><p>This ECG will allow instructors to discuss with their students:</p><p>* &nbsp;which leads reflect changes from which parts of the heart</p><p>* &nbsp;what the ECG signs of acute M.I. are</p><p>* &nbsp;the pathophysiology of pathological Q waves</p><p>* &nbsp;the effect of damage to various parts of the heart on the patient's condition and symptoms</p><p>This "classic" M.I. pattern should be taught to all health care professionals who work in settings where ECG is used.</p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/301/feed" method="post" id="fivestar-custom-widget--8" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--16" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Acute Anterior-Lateral Wall M.I. 1/5</option><option value="40">Give Acute Anterior-Lateral Wall M.I. 2/5</option><option value="60">Give Acute Anterior-Lateral Wall M.I. 3/5</option><option value="80">Give Acute Anterior-Lateral Wall M.I. 4/5</option><option value="100" selected="selected">Give Acute Anterior-Lateral Wall M.I. 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4.3</span></span> <span class="total-votes">(<span >12</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--8" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-W-I4U_JkTvIBzblD2rj3DepcyI-wcYGT3P6IjcHjUII" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">STEMI</a></div><div class="field-item odd"><a href="/ecg/anterior-wall-mi-5" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Anterior wall M.I.</a></div><div class="field-item even"><a href="/ecg/proximal-occlusion-lad" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Proximal occlusion of LAD</a></div><div class="field-item odd"><a href="/ecg/st-elevation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST elevation</a></div><div class="field-item even"><a href="/ecg/pathological-q-waves" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Pathological Q waves</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_8"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Facute-anterior-lateral-wall-mi&amp;title=Acute%20Anterior-Lateral%20Wall%20M.I."><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Fri, 25 Apr 2014 20:01:47 +0000 Dawn 568 at https://www.ecgguru.com https://www.ecgguru.com/ecg/acute-anterior-lateral-wall-mi#comments Previous Inferior Wall M.I. and Left Axis Deviaton https://www.ecgguru.com/ecg/instructors-collection-ecg-week-january-17-2014-previous-inferior-wall-mi-and-left-axis-deviat-1 <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/instructors-collection-ecg-week-january-17-2014-previous-inferior-wall-mi-and-left-axis-deviat-1"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/IW117.jpg" width="1800" height="1406" alt="" /></a></div><div class="field-item odd"><a href="/ecg/instructors-collection-ecg-week-january-17-2014-previous-inferior-wall-mi-and-left-axis-deviat-1"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/Axis%20around%20-70%20ALAD.jpg" width="400" height="359" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p>If you are teaching frontal plane axis to your students, you will need to teach them HOW to determine the axis - usually beginning with the QRS axis and then adding the P and T waves. &nbsp;But, you also need to teach them WHY we measure axis, to provide relevance to something that may seem challenging to beginners. &nbsp;There are many ECG interpretations that rely heavily or are dependent upon the determination of the axis. &nbsp;</p><p>This ECG is a great example of left axis deviation. &nbsp;The cause is readily discernible, if your students know the ECG signs of myocardial infarction. This patient had an inferior wall M.I. in the distant past, and now has pathological Q waves in Leads II, III, and aVF. &nbsp;Pathological Q waves in related leads in a patient with history of M.I. are a sign of necrosis, or permanent damage, in that part of the heart. &nbsp;The inferior wall has lost an extensive amount of tissue, which is now electrically inactive as well as mechanically inactive. &nbsp;(You may also find it helpful to show students videos of ventriculograms showing<a title="Normal LV gram " href="http://ecgguru.com/ecg-resource/normal-ventriculogram"> normal LV function</a> and <a title="Hypokinesis of LV" href="http://ecgguru.com/ecg-resource/ventriculogram-stunned-inferior-wall">hypokinesis of the LV</a> due to M.I.) &nbsp;Because of the loss of electrical activity in the inferior wall, the "mean" electrical direction (or axis) is AWAY from the inferior wall. &nbsp;That is, the electricity travels AWAY from II, III, and aVF and TOWARD I and aVL.</p><p>Many of the blogs and webpages listed in our "Favorites" address the subject of axis determination. &nbsp;Here is one from <a title="Cardio Rhythms Online" href="http://cardiorhythmsonline.blogspot.co.uk/">Cardio Rhythms Online</a> if you would like a review.</p><p>&nbsp;</p><p>&nbsp;</p><p>&nbsp;</p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/301/feed" method="post" id="fivestar-custom-widget--9" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--18" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Previous Inferior Wall M.I. and Left Axis Deviaton 1/5</option><option value="40">Give Previous Inferior Wall M.I. and Left Axis Deviaton 2/5</option><option value="60">Give Previous Inferior Wall M.I. and Left Axis Deviaton 3/5</option><option value="80">Give Previous Inferior Wall M.I. and Left Axis Deviaton 4/5</option><option value="100">Give Previous Inferior Wall M.I. and Left Axis Deviaton 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="empty">No votes yet</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--9" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-MeOi7lI_b5KW6JIPLy2JHSqzz2nAsoDixfjLCK0DOkw" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/inferior-wall-mi-0" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Inferior Wall M.I.</a></div><div class="field-item odd"><a href="/ecg/left-axis-deviation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left axis deviation</a></div><div class="field-item even"><a href="/ecg/pathological-q-waves" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Pathological Q waves</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_9"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Finstructors-collection-ecg-week-january-17-2014-previous-inferior-wall-mi-and-left-axis-deviat-1&amp;title=Previous%20Inferior%20Wall%20M.I.%20and%20Left%20Axis%20Deviaton"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Sat, 18 Jan 2014 03:39:39 +0000 Dawn 546 at https://www.ecgguru.com https://www.ecgguru.com/ecg/instructors-collection-ecg-week-january-17-2014-previous-inferior-wall-mi-and-left-axis-deviat-1#comments Recent Anterior-Septal Wall M.I. With Right Bundle Branch Block https://www.ecgguru.com/ecg/recent-anterior-septal-wall-mi-right-bundle-branch-block <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/recent-anterior-septal-wall-mi-right-bundle-branch-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/AWRB103_0.jpg" width="1800" height="1359" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p>This is an ECG from a 95 year old man who was recovering from an anterior-septal wall M.I. &nbsp;Other clinical data for this patient has been lost, except that he suffered a new right bundle branch block during this M.I. &nbsp;The ECG shows pathological Q waves in V1, V2, and V3, consistent with permanent damage (necrosis) in the anterior septal wall. &nbsp;The ST segments in those leads are coved upward. &nbsp;Even though the J points are not elevated, this ST segment shape suggests recent injury. &nbsp;The classic RBBB pattern is present: &nbsp;wide QRS, rSR' pattern in V1, and wide little s waves in I and V6. &nbsp;It is not known why the overall voltage is low in this patient.</p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/301/feed" method="post" id="fivestar-custom-widget--10" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--20" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Recent Anterior-Septal Wall M.I. With Right Bundle Branch Block 1/5</option><option value="40">Give Recent Anterior-Septal Wall M.I. With Right Bundle Branch Block 2/5</option><option value="60">Give Recent Anterior-Septal Wall M.I. With Right Bundle Branch Block 3/5</option><option value="80">Give Recent Anterior-Septal Wall M.I. With Right Bundle Branch Block 4/5</option><option value="100" selected="selected">Give Recent Anterior-Septal Wall M.I. With Right Bundle Branch Block 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4.3</span></span> <span class="total-votes">(<span >7</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--10" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-GH9atEMVsg7P0kJsOB7kzEvJ8lE5-STcUtVCNCmxAAk" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/anterior-septal-wall-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Anterior-septal wall M.I.</a></div><div class="field-item odd"><a href="/ecg/anterior-wall-mi-5" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Anterior wall M.I.</a></div><div class="field-item even"><a href="/ecg/pathological-q-waves" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Pathological Q waves</a></div><div class="field-item odd"><a href="/ecg/rbbb" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">RBBB</a></div><div class="field-item even"><a href="/ecg/bundle-branch-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Bundle branch block</a></div><div class="field-item odd"><a href="/ecg/right-bundle-branch-block-1" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Right bundle branch block</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_10"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Frecent-anterior-septal-wall-mi-right-bundle-branch-block&amp;title=Recent%20Anterior-Septal%20Wall%20M.I.%20With%20Right%20Bundle%20Branch%20Block"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Fri, 19 Apr 2013 04:17:09 +0000 Dawn 434 at https://www.ecgguru.com https://www.ecgguru.com/ecg/recent-anterior-septal-wall-mi-right-bundle-branch-block#comments