EKG case

[Jabbed]

55 y/o black male with three days of transient positional and pleuritic chest pain.



No prior EKG or ECHO for comparison. Poor historian, but claims no hx of lung disease. Troponin positive, but concomitant renal failure. Thoracic aneurysm on CT.

Thoughts:
1. ST elevation in right precordials and aVR with inferolateral depressions looks like LMA or proximal LAD lesion. Inferolateral ischemia with sinus tachycarida and P pulmonale also made me think of PE given the symptoms, although the CT was clean.
2. The marked P pulmonale makes me wonder if the ST deviations are d/t atrial repolarization.
3. PR is oddly short at 106 ms. Sub-clinical LGL syndrome or high atrial tachycardia?

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[Trifling Jester]

You won't know until you cath.

 

[Jabbed]

You won't know until you cath.

STE and tachycardia resolved in the ED, the decision was made not to cath.

 

[IMDoc607]

Ectopic atrial tachycardia? It is sinus the p waves have a different morphology.

 

[Instatewaiter]

Ectopic atrial tachycardia? It is sinus the p waves have a different morphology.

The P wave seems to have a reasonable axis so if it is an EAT the focus would have to be rather close to the sinus node.

 

[IMDoc607]

I showed one of my attendings and he wasn't convinced it was EAT either. He was exactly sure. The guy is awsome to. I wish we could set up a forum where we discuss interesting ECG's but I am not sure if thats possible.

 

[turkeyjerky]

STE and tachycardia resolved in the ED, the decision was made not to cath.

55 yom w/ risk factors, dynamic EKG changes and a positive troponin and no cath? Interesting...

 

[nstemi]

patient needs a cath (or at the very least a stress test)

as for the ekg: likely sinus tach. it appears the fourth beat (and seventh, etc) have different p-wave morphologies and come slightly early likely making them pac's. patient has lvh, left atrial enlargement, and right atrial enlargement based on ekg criteria. remember that st-depression does not localize to areas of ischemia, only st-elevation does. st-elevation in avr is concerning for 3-vessel disease. does the p-wave morphology look the same on follow-up ekg's when his rate slowed? a rate of 110 would not be the main cause of those st-depressions in an otherwise healthy 55 year old (180 maybe, but not 110). he also has a thoracic aortic aneurysm which certainly raises the possibility that he has other underlying cardiovascular risk factors. he also has chronic kidney disease (i presume from your description) which is a risk factor in itself for cvd. what makes you think he doesn't have coronary disease? have i convinced you yet?

what did his cath/stress and echo show?