What is the Etiology of the Tall Initial R Wave in V1-V2?

We present an electrocardiogram that may be passed on as showing a simple right bundle branch block, but for the vigilant interpreter, a posterior infarction could be easily gleaned from the presence of a tall initial R wave in V1-V2.

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.

Electrocardiogram in a 75-Year-Old Woman With Left-Sided Chest Pain.

In a 75-year-old woman with left-sided chest pain and an abnormal electrocardiogram the etiology is not cardiac.

Sudden cardiac arrest as the initial presentation for left ventricular noncompaction cardiomyopathy.

A 37-year-old man without a significant medical history had an out-of-hospital sudden cardiac arrest. A bystander started cardiopulmonary resuscitation, and emergency medical services arrived promptly, confirmed ventricular fibrillation, and restored sinus rhythm. An emergent coronary arteriogram was normal. Transthoracic echocardiography revealed a severely reduced left ventricular ejection fraction and suggested left ventricular noncompaction. The patient's heart failure with reduced ejection fraction was treated with carvedilol, lisinopril, and spironolactone, and after he was weaned from the ventilator he received an implantable cardioverter-defibrillator. The patient's identical twin was treated in the same fashion for a sudden cardiac arrest. Although many experts think that left ventricular noncompaction cardiomyopathy is a distinct nosological entity, others think that it is simply a dilated cardiomyopathy with unusually prominent left ventricular trabeculae.

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.

Ventricular Septal Defect in a 66-Year-Old Man.

A 66-year-old man presented with a moderate-sized ventricular septal defect and severe pulmonary hypertension that was responsive to vasodilator therapy. His electrocardiogram demonstrated biatrial enlargement and biventricular hypertrophy. Presentation at this age is unusual for this type of shunt.

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.

Dynamic ST-Segment Abnormality.

A 37-year-old man came to the emergency department because of several days of intermittent chest pain. An electrocardiogram (ECG) showed sinus rhythm, left atrial and left ventricular enlargement, and an early repolarization pattern. A second ECG recorded 10 minutes later was strikingly different, with ST-segment elevation and large upright T waves in the anterior precordial leads, interpreted as evidence of an ST-segment elevation myocardial infarction, and the cardiac catheterization team was activated. Closer inspection of the ECG, however, disclosed that the changes were because of intermittent ventricular pre-excitation of the Wolff-Parkinson-White type, and no electrocardiographic, echocardiographic, or serum markers of myocardial infarction were found.

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.

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).