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Instructors' Collection ECG: Isolated Posterior Wall M.I.

Submitted by Dawn on Sat, 11/11/2023 - 15:51

This interesting case was provided by Dr. Bojana Uzelac, Emergency Medicine physician.  We are paraphrasing a translation of her comments here.

The patient is a 50-year-old complaining of chest pain.

The ECG shows a rare occurrence – an isolated POSTERIOR WALL MI (PWMI).  Note that leads V1 through V4 show the usual signs of posterior wall MI.  We see ST segment depression, which represents a reciprocal view of the ST elevation present on the posterior wall of the left ventricle.  The relatively tall, wide R waves in V2 and possibly V3 represent pathological Q waves on the posterior wall. (V2 R/S ratio > 1). What is unusual here is that there are no signs of inferior wall MI or lateral wall MI.  Posterior wall MI usually occurs in conjunction with one of these.

 PWMI is most often seen as an extension of inferior wall MI or lateral wall MI, because of shared blood supply.  Usually, it is the right coronary artery that supplies both the posterior and inferior areas of the left ventricle (about 80% - 85% of the population).  In some individuals, the circumflex artery supplies both areas. Posterior M.I. may also be seen in conjunction with lateral wall MI, when the circumflex supplies the posterior and lateral walls.  In the case shown here, only the posterior wall is involved.  Most cases of isolated PWMI involve either the circumflex or one of its marginal (OM) branches.  Only about 3.3% - 5% of all MIs are isolated PWMI.

 

Dr A Röschl's picture

Sinus Bradycardia and More

Submitted by Dr A Röschl on Mon, 11/20/2023 - 03:40

Let's analyze the ECG. It comes from a pacemaker patient whose pacemaker was briefly switched to VVI at 30 bpm due to a stimulation threshold test. The first 3 beats show a sinus rhythm with a frequency of approx. 40 bpm. This is followed by a premature ventricular contraction (PVC). The P wave of the next sinus node beat lands exactly on the T of the PVC. This cannot be conducted to the ventricles, either because the ventricular myocardium is still unexcitable or the PVC has conducted retrogradely into the AV node and this is therefore still refractory.

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SMART WATCH ECG

Submitted by Dr A Röschl on Sun, 11/19/2023 - 04:52

Many people are considerably unsettled by ECG recordings from smart watches. However, smartwatch ECGs can be helpful in the diagnosis of paroxysmal atrial fibrillation. Here. you can see an example. It is a 1-channel ECG that corresponds to lead I. Initially there is an irregular fast pulse without P waves, which corresponds to a tachyarrhythmia in atrial fibrillation. At the end of the first line, after a very short pause, there is sinus rhythm. In the third line you see a short SVT over 3 beats, then SR again. The QRS complex is widened to over 120 ms.

Dr A Röschl's picture

ATYPICAL ATRIAL FLUTTER (FROM THE LEFT ATRIUM)

Submitted by Dr A Röschl on Mon, 11/13/2023 - 08:07

Why is this atypical atrial flutter from the left atrium?

Dr A Röschl's picture

Ventricular Tachycardia

Submitted by Dr A Röschl on Tue, 10/24/2023 - 05:34

There are several differential diagnoses in the presence of broad-complex tachycardia. The most common cause of wide-complex tachycardia is ventricular tachycardia. In 2nd place is sinus tachycardia/supraventricular tachycardia with aberrant conduction or preexisting bundle branch block.

Dr A Röschl's picture

Right Bundle Branch Block

Submitted by Dr A Röschl on Tue, 10/24/2023 - 04:59

Why is this a right bundle branch block? We see a SR with broad QRS complexes (more than 120 ms). These are positive in the rightward leads III and especially in V1 and V2. In the more leftward leads I, aVL, V4-V6 there are clear S waves. This is a typical RBBB pattern.

Dr A Röschl's picture

Left Bundle Branch Block

Submitted by Dr A Röschl on Tue, 10/24/2023 - 04:50

Why is this a left bundle branch block? We see a SR with broad QRS complexes (more than 120 ms). These are positive in the leftward leads I and aVL and in V5 and V6. In the more rightward leads III, aVR, and V1-V3, the QRS complexes are predominantly negative with deep S waves. This is a typical LBBB pattern.

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ECG Basics: Ventricular Fibrillation Seen In Twelve Leads

Submitted by Dawn on Fri, 05/19/2023 - 15:07

This is an image of ventricular fibrillation as seen in all twelve standard leads simultaneously.  This is cardioplegic ventricular fibrillation, occurring as the heart is stopped during cardiopulmonary bypass for open heart surgery.  Each channel (horizontal strip) is run during the same ten-second period.  Our thanks to Dr. Andreas Röschl from Germany for contributing this image.

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Ask The Expert

Submitted by Dawn on Fri, 10/01/2021 - 14:38

Dr. Jerry W. Jones, MD, FACEP, FAAEM has graciously shared with us his four-part article on the topic of “Delays & Blocks Involving the Bundle Branches”.

Dr. Jones is a talented instructor who makes difficult topics easy.  Please feel free to post your comments and questions for Dr. Jones and our other ECG Gurus. 

Click THIS LINK for a downloadable pdf of Part 1: Non-Specific Intraventricular Conduction Delays. 

Click THIS LINK for a downloadable pdf of Part 2: Left Bundle Branch Block.

Click THIS LINK for a downloadable pdf of Part 3: Right Bundle Branch Block.

Click THIS LINK for a downloadable pdf of Part 4: The Fascicles of the Left Bundle Branch 

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ECG Glossary from Dr. Ken Grauer

Submitted by Dawn on Sat, 06/08/2019 - 14:16

Are you looking for a comprehensive ECG glossary that goes beyond simply defining words? Dr. Ken Grauer, who is the ECG Guru's Consulting Expert, has a Glossary available on his website that explains the terms.  Instructors and students alike will benefit from having this glossary readily available.  The glossary is exerpted from his e-Publication, "A 1st Book On ECGs - 2014", available on Amazon.

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Dr. Ken Grauer Glossary

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