EM Alliance ECG – Case 10

54 yof, presyncope, palpitations, currently asymptomatic.

ECG courtesy of  http://www.emalliance.org/


8 Comments Add yours

  1. Tatsu Kuwasaki says:

    Thank you for those sharing your thoughts as not only we all learn from your knowledge, but also it is really inspiring.
    I hope you guys are enjoying this ECG series, but if you’ve just joined our blog, please go back and start from the first post as we are talking slightly geeky ECGs now…

    Liked by 1 person

  2. Tatsu Kuwasaki says:

    Well, nice work guys and there are some very impressive display of knowledge out there!
    Right sided strain was noted by some and I can totally see the rationale for some of you guys are thinking PE.

    OK, this ECG was really tricky. The correct answer is a condition called ARVD or ARVC (Arrythmogenic Right Ventricualr Dysplasia/Cardiomyopathy) and the keyword was “presyncope” and hardly recognisable ECG abnormality “Epsilon Waves” (jaggedy waves) on V1~V3, * Please note the Epsilon Waves only accounts for approx 30% of the cases.
    As the name suggests, it’s a non-ischaemic cardiomyopathy can cause fatal arrythmia. 80% of the case is found by either sycope or sudden death.

    You are certainly the geek of the month if you got the right diagnosis but the key learning point this month is about the checklist you should go over for presyncope/syncope. My ECG God Dr Mattu recommends we should go through the same list post cardiac arrest so here it is.

    Post-Arrest and Syncope ECG Differential

    Dysrhythmias, AVB’s
    Prolonged QT (and short QT, especially in pediatrics)
    Hypertrophic Cardiomyopathy
    Brugada pattern
    Arrhythmogenic right ventricular dysplasia (ARVD)
    Miscellaneous (PE, electrolytes, ICB, etc.)

    ARVD ECG Findings (imperfect)
    Leads V1-V3
    Epsilon waves (most specific)
    TWIs (most sensitive)
    Slight prolongation of QRS
    LBBB type VT or PVCs (many)

    ARVD: Heightened Concern if

    Young patients, especially males
    Family history of early sudden death
    Many PVC’s
    LBBB-type Ventricular Tachycardia
    Epsilon waves with TWI’s in V1-V3


    Basso C., et al. Arrhythmogenic right ventricular cardiomyopathy. Lancet 2009;373(9671):1289–1300. PMID: 19362677

    Diez D, Brugada J. Diagnosis and Management of Arrhythmogenic Right Ventricular Dysplasia: An article from the E-Journal of the ESC Council for Cardiology Practice, European Society of Cardiology 2008 [Full text].

    Electrocardiographic Features of Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy According to Disease Severity http://circ.ahajournals.org/content/110/12/1527


  3. jackbloods says:

    I’m leaning towards PE here Tatsu; We got what would appear to be some R Vent hypertrophy at the least; R vent strain pattern, R axis deviation, dominant R-wave in V1, perhaps some minor non-specific T and ST changes. Low percentage diagnostic signs for PE I know, but several of them. Not tachycardia however which I would expect. PE can present with syncope too, I would require some thorough examination of the pt to rule it out..

    Liked by 1 person

  4. Mahiaboi says:

    Potentially the patient could have Wellens sign which could explain the presyncopic event….

    Liked by 1 person

  5. Tatsu Kuwasaki says:

    Good point about “Always look at the clinical presentation”, however in this case the only hint I can give you is a question.
    Do you have a list of conditions you go over for presyncope pts?


    1. jumbojs says:

      Naturally a full assessment et cetera, however just looking at this ECG in line with the given symptoms, perhaps a posterior cardiac event or atypically presenting anterior ischaemia?

      Liked by 1 person

      1. jackbloods says:

        As far as a list of causes for syncope they have a couple of real good tools here Jumbo.

        Liked by 1 person

  6. minninz says:

    Hi there
    Are you going to supply more info or is this just about ECG interpretation? 🙂
    Gut says explore history, BP, medications….
    T wave issues are a start 🙂

    Liked by 1 person

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