1. ECG QUIZ
Tricky ED ECGs -
‘The Magnificent 7’ in
‘To cath or not to cath’..
Dr Jono Holme
2. ECG 1
Where / What is the abnormality?
What is the importance of the abnormality?
What do we do about it?!
35 yo male, diaphoretic, now pain - free
3. ANSWER:
There are T-wave inversions in V3 and V4, lead III and aVF with BIPHASIC T-waves
in V2 and V3.
These BIPHASIC T- waves in V2 / V3 are highly specific for a CRITICAL
STENOSIS of the LEFT ANTERIOR DESCENDING coronary artery.
These findings are known as a WELLEN’S SYNDROME
These patients are often PAIN FREE at the time of their ECG as the BIPHASIC T-
waves indicate coronary reperfusion. If the artery remains open, they will progress
from a TYPE A to a TYPE B. If the artery re-occludes, HYPER-DYNAMIC T-
waves will develop and PAIN will reoccur
This patient needs referral for an angiogram within 24 hours. If treated medically they
will do poorly, and if sent for a treadmill test, they could have a fatal arrhythmia
Type A Type B Hyper-dynamic
Re-perfusion Re-occlusion
4. ECG 2
Where / What is the abnormality?
What is the importance of the abnormality?
What do we do about it?!
51 yo male, 8/10 chest pain
5. ANSWER:
There is ST depression in leads I and II, with ST depression and HYPER-ACUTE T-
waves in the precordial leads.
This ST DEPRESSION with HYPER-ACUTE T-waves in the PRECORDIAL
leads is known as DE - WINTER’s PATTERN
This pattern is an ANTERIOR STEMI EQUIVALENT WITHOUT
ST ELEVATION
It is seen in 2% of Left Anterior Descending coronary artery occlusions, and requires swift
CATH LAB ACTIVATION
6. ECG 3
Where / What is the abnormality?
What is the importance of the abnormality?
What do we do about it?!
58 yo male, 10/10 chest pain
7. ANSWER
There is ST depression in leads V2 - V3, ? slight ST elevation lead III
This is a POSTERIOR STEMI, occurring in 25% of STEMIs , usually occurring in
the context of other inferior or lateral STEMIs. Posterior extension of one of these
infarcts implies a larger area of myocardial damage, resulting in higher mortality
It is sometimes MISSED because of the ST depression appearance at V2 - V3
Posterior leads
The posterior chest leads reveal the ST DEPRESSION to be ST ELEVATION
This patient needs to be taken to the CATH LAB
The anteroseptal leads are directed from the anterior precordium towards the internal surface of the
posterior myocardium. Because posterior electrical activity is recorded from the anterior side of the
heart, the typical injury pattern of ST elevation and Q waves becomes inverted
8. ECG 4
Where / What is the abnormality?
What is the importance of the abnormality?
What do we do about it?!
22 yo 2/10 chest pain, palps, syncope
9. ANSWER
T - wave inversions II, III, aVF, V4 - V6
Did you notice the delta - waves?
This patient has WPW or WOLFF-PARKINSON-WHITE
Short PR interval <120 ms, delta waves - slurring slow rise of the initial portion of the
QRS segment. The ST segment and T - wave discordant changes reflect a ‘pseudo
infarction pattern’ due to accessory pathway conduction.
The T-wave inversions in V4-V6 reflects the
‘pseudo - infarction’ pattern of WPW as seen on
the left, NOT LVH
This is a right sided accessory pathway
- a TYPE B WPW
A Type A WPW demonstrates T-wave inversions
from V2 - V3. This shows a left sided accessory
pathway
This patient needs referral to a cardiologist for further testing
10. ECG 5
Where / What is the abnormality?
What is the importance of the abnormality?
What do we do about it?!
35 yo collapse, no chest pain
11. ANSWER
V1/V2 have ‘SADDLEBACK ST CHANGES’ - BRUGADA syndrome
BRUGADA is an ECG abnormality with a high incidence of sudden death in patients
with structurally normal hearts. It is due to a mutation in the cardiac SODIUM
CHANNEL. ECG changes can be transient, and are often unmasked by fever,
trauma, ischaemia or drugs, so we are often the only ones to see these changes.
Definitive treatment is with an Implantable Cardiac Defibrillator
Diagnosis depends on these ECG changes AND CLINICAL CRITERIA
The ECG findings in ISOLATION are of
questionable significance
They need to be associated with a history of
syncope, arrhythmia, or family history of
sudden cardiac death
However, this is a rare ECG finding, and if
you find it, you should discuss it with a
cardiologist.
12. ECG 6
Where / What is the abnormality?
What is the importance of the abnormality?
What do we do about it?!
27 yo pregnant female, collapse, no chest pain
13. ANSWER
T-wave inversion II, III, aVF, V2-V6 (seen in 85% at V1-V3)
‘Epsilon waves’ (seen in 30%)
These Epsilon waves are characteristic of an ‘ARVC’
EPSILON WAVES - small peak following s-wave
ARVC stands for Arrhythmogenic Right
Ventricular Cardiomyopathy
It is a genetic disorder that involves weakness
developing in the right ventricle of the heart,
with resultant changes in the way electricity is
conducted around it.
It has an association with
SUDDEN CARDIAC DEATH.
ALL patients need cardiology referral
The most specific and subtle finding is a
‘prolonged S-wave upstroke’ V1-3
14. ECG 7
Where / What is the abnormality?
What is the importance of the abnormality?
What do we do about it?!
19 yo athlete, collapse during marathon
15. ANSWER
Difficult right?!
Increased precordial voltages
‘Dagger like Q - waves’ V5-V6, I, aVL, II, III, aVF
This patient has HOCM - Hypertrophic Obstructive Cardiomyopathy
It is an inherited disease where the left ventricle hypertrophies until it obstructs its
own outflow. This LEFT VENTRICULAR HYPERTROPHY is visible on some
ECGs, namely as the deep T - wave inversions with tall r- waves in V4 - V6
HOCM is the number one cause of
sudden cardiac death in young
athletes
annual mortality is 1-2% for these
individuals
EXERTIONAL SYNCOPE,
CHEST PAIN OR PALPITATIONS
are the symptoms. REFER ANY
PATIENT with this history and these
ECG findings
