Tombstone Sign in an Inferior Wall Myocardial Infarction

A 62-year-old white patient presents with markedly ischemic electrocardiogram, notable for Tombstone sign.

Arrhythmia With an Exercise Test

A 64-year-old man with known coronary disease presented to the hospital with sinus bradycardia, chest pain, and normal cardiac enzymes. During an exercise stress test he developed ventricular fibrillation that spontaneously resolved.

Chest and Back Pain

A man with an acute anterolateral myocardial infarct had electrocardiographic features suggesting triple vessel coronary arterial disease and infarct-related regional pericarditis.

Treadmill Stress Test in a 56-Year-Old Man

Several findings on an exercise electrocardiogram predicted left main and/or 3-vessel coronary arterial disease, which was confirmed by coronary arteriography, and the 56-year-old man underwent a multivessel coronary arterial bypass operation the following day.

Chest Pain and Electrocardiographic Changes

A 58-year-old man with his first episode of chest pain had an acute anterior myocardial infarct. After balloon angioplasty and stenting of a completely occluded left anterior descending coronary artery, the anterolateral ST-T changes had largely resolved.

Syncope, Junctional Premature Complexes, and Pseudo-Type II Atrioventricular Block

In a woman with syncope, junctional premature complexes and what appeared to be intermittent atrioventricular block suggested concealed conduction of His bundle extrasystoles.

Malignant Early Repolarization

A 27-year-old man presents with successfully resuscitated ventricular fibrillation. Structural and electrical causes of ventricular fibrillation in the young are presented along with a diagnostic strategy. Electrocardiographic features of malignant early repolarization are discussed.

Wide-QRS Complex Tachycardia

In a man with a wide-QRS complex tachycardia, a history of an inferior left ventricular scar, atrioventricular dissociation during the tachycardia, and a QRS morphology inconsistent with right or left bundle branch block exclude a diagnosis of supraventricular tachycardia with aberrant ventricular conduction due to bundle branch block or ventricular preexcitation and establish a diagnosis of ventricular tachycardia.

Acquired Heart Disease Superimposed on Congenital Heart Disease

A 50-year-old man with a murmur since birth developed systemic arterial hypertension as an adult. He came to the hospital because of dyspnea. He had a pulmonic valve ejection click and a murmur of pulmonic stenosis. His echocardiogram showed biventricular hypertrophy, a flat ventricular septum, a D-shaped left ventricle, systolic doming of the pulmonic valve, and Doppler evidence of a 70 mm Hg peak systolic pressure gradient across the pulmonic valve and a peak right ventricular systolic pressure of 100 mm Hg. His electrocardiograms showed no evidence of the right ventricular and right atrial enlargement so evident on echocardiogram, presumably because it was obscured by the marked changes of left ventricular hypertrophy. Three years later, when he was admitted for sepsis and worsening heart failure with anasarca, the voltage changes of left ventricular hypertrophy had virtually disappeared, likely due to the large amount of fluid between the heart and the electrodes.

Double-Chambered Right Ventricle in a 49-Year-Old Man

Most patients with double-chambered right ventricles are diagnosed in childhood, but some escape definitive diagnosis until adulthood, as was the case in the patient described here.

Bradycardia, Syncope, and Left Ventricular Noncompaction Cardiomyopathy

A 55-year-old man with syncopal episodes was found to have sinus bradycardia at a rate of 37 beats/min, an episode of nonsustained ventricular tachycardia, and left ventricular noncompaction cardiomyopathy. After placement of a dual-chamber cardioverter defibrillator 4 years ago, he has had no further syncopal episodes, and there have been no defibrillator shocks.

Sinus Tachycardia With Variable QRS Morphology

Wolff-Parkinson-White-type ventricular preexcitation was recognized for the first time in a 67-year-old man four days after aortic valve replacement. The preexcitation was intermittent.

ECG Case of the Month: Wide-QRS Rhythm in a Man with a Clotted Dialysis Fistula

A 57-year-old man with diabetes mellitus, systemic arterial hypertension, and end-stage kidney disease came to the hospital because his arteriovenous fistula used for hemodialysis had clotted. His blood hemoglobin level was 12.8 g/dL (reference, 13.5-17.5); and serum chemistry levels were creatinine 6.7 mg/dL (0.7-1.3), sodium 132 mEq/L (136-146), potassium 4.0 mEq/L (3.5-5.1), chloride 94 mEq/L (98-106), carbon dioxide 24 mEQ/L (23-29), calcium 9.1 mg/dL (8.4-10.2), and phosphorus 9.1 mg/dL (2.7-4.5). An electrocardiogram was recorded (Figure 1).

Chest Pain and ST-Segment Elevation in an 18-Year-Old Man

An 18-year-old man came to the hospital because of 1 day of chest pain typical of pericarditis. He had had an upper respiratory infection 10 days earlier. His electrocardiograms indicated evolving pericarditis. His echocardiogram showed mild, diffuse left ventricular hypokinesia, and his troponin I level peaked at 47.5 ng/ml. Thus, he had myopericarditis.

The Value of Reciprocal Electrocardiographic Leads

In a woman with chest pain, <0.1 mV ST-segment elevation in lead III, and virtually no ST elevation in leads II and aVF, striking ST-segment depression in lead aVL, the reciprocal lead to lead III, confirmed the diagnosis of acute inferior myocardial infarction.

ECG Of The Month: Mental Disturbance for 4 days

A family brought their 61-year-old mother to the emergency department because for 4 days she had been confused, incoherent, and somnolent. She also had dysphagia, dysarthria, diplopia, and had fallen out of bed. She had been in the hospital 3 weeks earlier for atrial fibrillation and an exacerbation of congestive heart failure. She also carried a diagnosis of chronic obstructive pulmonary disease and used an albuterol inhaler. She was obese (BMI of 45); and had adult-onset diabetes mellitus. She had a 43 pack-year history of cigarette smoking but had recently quit. Soon after arriving in the emergency department, she had an ECG (Figure);.

ECG of the Month: Confusion and a Slow Heart Rate

Police found a confused 93-year-old woman wandering the streets and brought her to the hospital where an electrocardiogram (ECG) was recorded.

Lower Extremity Paralysis

Severe hypokalemia in the absence of other electrolyte abnormalities, the result of diarrhea, caused striking electrocardiographic changes, generalized weakness, flaccid paralysis of the lower extremities, and biochemical evidence of mild skeletal and cardiac rhabdomyolysis in a 33-year-old man. Repletion of potassium reversed all abnormalities in 24 hours.

ECG of the Month: Wide-QRS Tachycardias

A 61-year-old man came from out of state to attend a football game. He felt well during the game, but when he stood up to leave, he became dizzy and dyspneic. The symptoms lasted 15 to 20 minutes, and when the paramedics arrived, they diagnosed an idioventricular rhythm and brought the patient to the emergency department where a 12-lead electrocardiogram (ECG) was recorded (Figure 1).

ECG Case of the Month: Heart Failure in a Man from Chile

A 49-year-old man visiting New Orleans from Chile comes to the hospital complaining of exertional dyspnea for 2 months with the more recent onset of ankle edema. He is a slender man with a blood pressure of 91/60 mmHg, crackles at both lung bases, and markedly distended neck veins. His cardiac rhythm is irregular. A soft murmur of mitral regurgitation and a soft S-3 are heard at the left ventricular apex. All four pedal pulses are easily palpable. Epigastric tenderness is noted on palpation; although the patient has a history of peptic ulcer disease, the tenderness is probably due to an enlarged left lobe of his liver, the result of hepatic congestion from his heart failure. A chest radiograph shows generalized cardiomegaly with an especially large left ventricle. Pulmonary congestion and small bilateral pleural effusions also are noted. The Figure shows the electrocardiogram recorded on admission.

ECG of the Month: Subtle ECG Change in a 31 Year-Old Man with Recent Chest Pain

A 31-year-old man had an hour of pain across the upper portion of his chest anteriorly, and it radiated down the inner aspects of both arms. The pain came while he was walking and gradually disappeared as he sat quietly. Six Rolaid tablets did not seem to alter the pain. The pain was unaccompanied by dyspnea, sweating, nausea or vomiting. The night before the patient had had similar pain relieved by Rolaids and belching. After the second episode of pain, he went to the emergency department of a local hospital where an ECG was recorded.

ECG Of The Month: Sepsis, ARDS, and Tracheal Intubation

A furuncle on the leg of a 23-year-old woman led to methicillin-resistant staphylococcus aureus sepsis and adult respiratory distress syndrome (ARDS) requiring tracheal intubation in the intensive care unit (ICU). Initially her electrocardiograms (ECGs) showed sinus tachycardia, but otherwise were unchanged from prior ECGs. A week into her ICU stay a different rhythm occurred.

Chest Pain, Heart Murmur, and Changing Electrocardiograms

Physical examination, electrocardiograms, and an echo-Doppler study document multiple consequences of a right coronary arterial occlusion.

ECG Of the Month: Suicide

Apparently depression ran in this man's family, and when he took an overdose of his tricyclic antidepressant, he also took the tricyclics of his mother and his sister. Most patients who die of an overdose of a tricyclic antidepressant are pronounced dead without reaching a hospital, and those who die after arriving in the emergency room do so within a few hours.2 Central nervous system toxicity of tricyclic antidepressants may manifest as confusion, agitation, hallucinations, coma, myoclonus, or seizures. Generalized seizures often presage cardiopulmonary arrest,2 and within 20 seconds of the ECG with evidence of generalized seizure activity shown here, the QRS duration increased from 188 ms to 212 ms, and the patient died soon thereafter.

ECG Case of the Month: IRREGULARLY IRREGULAR CARDIAC RHYTHM IN AN 87-YEAR-OLD WOMAN. MULTIFOCAL ATRIAL TACHYCARDIA; RIGHT BUNDLE BRANCH BLOCK

Multifocal atrial tachycardia; right bundle branch block. The rhythm is totally irregular at a rate of 103 beats/min and originally was read as atrial fibrillation. Close examination, however, reveals a P wave before each QRS and ≥ 3 different P- wave morphologies with no dominant morphology. These are the criteria for multifocal atrial tachycardia MAT, also known as chaotic atrial rhythm,1 chaotic atrial tachycardia,2 and chaotic atrial mechanism.3 The wide QRS complexes ≥ 0.12 s with broad S waves in leads I, aVL, and the lateral precordial leads and broad R or R´ waves in leads aVR and V1 indicate right bundle branch block. MAT is frequently seen in patients with acute pulmonary or other non-cardiac disease and tends to resolve when the underlying disease is brought under control. Patients with MAT also tend to have bouts of other arrhythmias,2 and 3 months earlier this.

ECG of the Month: ECG in an 81-Year-Old Woman

Sinus bradycardia (48 beats/min), long P-R interval (0.29 s), long QT interval (0.53 s with QTc of 0.47 s), and prominent J waves suggest hypothermia; non-specific ST abnormality.

ECG of the Month:Changing Morphology of a Wide-QRS Tachycardia

An obese 49-year-old man with a history of systemic arterial hypertension, diabetes mellitus, dyslipidemia, three myocardial infarcts, an ischemic cardiomyopathy, a four-vessel coronary artery bypass operation 7 years earlier, and implantation of a cardioverter-defibrillator 2 years earlier comes to the hospital with palpitations and dyspnea. An ECG is recorded.

ECG of the Month:A Forty-Year-Old Woman with a History of a Cardiac Operation at Age 5 Years

There is a sinus P wave in front of each QRS, and the rate is 122 beats/min. The QRS voltage is large and meets many criteria for left ventricular hypertrophy: RI > 13 mm (1.3 mV); RaVF > 19 mm; SaVR > 14 mm; SV1 > 24 mm; SV2 > 30 mm; RV6 > 26 mm; RV6 > RV5; SV1 + RV5 or RV6 > 35 mm; SV2 + RV5 or RV6 > 45 mm; RaVL + SV3 > 20 mm in a woman.1 In addition, there are two non-voltage criteria for LVH: QRS duration = 0.11 s and typical repolarization changes: J-point depression with a downsloping ST segment into an inverted T wave and a more rapid upslope back to the baseline. The prolonged QRS duration and repolarization changes are also typical of incomplete left bundle branch block (ILBBB). LVH is present in most patients with complete LBBB,2,3 and probably in most with ILBBB. The patient underwent aortic valvotomy at age 5 to relieve congenital stenosis. Although different valvular morphologies can result in aortic stenosis, when hemodynamically significant stenosis is present in infancy or early childhood the valve is usually unicuspid/unicommissural. Aortic valvotomy can greatly reduce the left ventricular outflow obstruction in such patients, but the majority eventually need reoperation. This usually means aortic valve replacement. This woman now has severe aortic stenosis and regurgitation with not only left but also right ventricular failure, which is a late development with pure aortic valve disease. She needs aortic valve replacement. Unfortunately having one severe disease does not preclude another, and her operative course will be complicated by multiple sclerosis which she developed some 12 years ago.

Myocardial Infarction and Left Ventricular Hypertrophy Seen on an Infant's Electrocardiogram

The clinical and electrocardiographic features of anomalous left coronary artery from the pulmonary trunk, ALCAPA, a frequently fatal congenital cardiac malformation, are described in an 8 1/2-month-old female.