The Patient:   This ECG was obtained from a 90-year-old woman who was complaining of feeling short of breath while lying in bed. Patient denied relevant medical history (respiratory or cardiac) and denied taking any medications. She also denied chest pain, nausea, or any other symptoms. She was found sitting upright in a recliner with mild subjective respiratory distress. She was completely alert and oriented, and was able to stand and transfer to the EMS stretcher.  We do not have a record of her initial vital signs or lung sounds, but her initial SPO2 on room air was 80%.  This improved to 100% on 15 L of O2 via NRB.  She was transported to the hospital without incident.

 The ECG:  The ECG shows a rate of 134 bpm.  The rhythm is regular.  P waves are difficult to see because of the muscle tension artifact and the rate. I strongly suspect there is a P wave at the end of the T – best seen in aVR, in which you can see the negative P wave right after the T.  The QRS is wide at 146 ms, and the QTc is borderline long at 465 ms, but is affected by the wide QRS being part of the measurement. There is, at this time, no simple and reliable method of evaluating QTc in the setting of wide QRS, but there are formulas available, and being evaluated.  

 The ECG shows a typical LEFT BUNDLE BRANCH BLOCK pattern. V1 has a negative QRS deflection, while Leads I and V6 have positive QRS complexes.  There is a leftward frontal plane axis. There are discordant ST changes – the ST segments deviate in the opposite direction of the QRS complexes.   Left bundle branch block is often seen in the context of heart disease, often myopathy.

Follow up:  The patient was found on echocardiography to have Takotsubo cardiomyopathy.  Her ejection fraction was 30%.  Because of her age and frailty, a cardiac catheterization was not done.  She was discharged home after three days.  Video of Takotsubo cardiomyopathy: https://youtu.be/d15kbYySnoY?si=D27e7Lb3ZAs6eGLq