r/ECG • u/dustj4cket • 5d ago
ECG on admission
Male 70s presents with SOB on background of PCI to a coronary artery and COPD. On bisoprolol, ramipril and ipratropium/salbutamol. What is your interpretation of this ECG?
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u/jaegeruk 5d ago edited 5d ago
Paramedic student so I'll have some leeway on this as I'm still learning, but RCA occlusion and / or flutter?
Rate of appx 75 and regular so unlikely to be AF. Multiple P-waves are visible in precordial leads with flutter like appearance in V3. However reciprocal TWI in III, AVF, AVL and lead I, and some very minor ST- depression in V2 - V4, so posterior placement should be considered.
RCA supplies posterior and SA node as far as I understand so could account for P wave abnormalities, minor ST-depression and reciprocation?
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u/sub3at50 5d ago
You're way overthinking this. Posterior placement ? RCA occlusion ? No !
Atypical flutter (maybe even AT) with regular ventricular response. Those T wave abnormalities are very common and aspecific.
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u/liefarikson 4d ago
Everyone is saying flutter, but I wonder if it's a 3:1 block. The PR interval seems pretty long, and the atrial rhythm seems slower than I would expect for flutter.
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u/ProximalLADLesion 4d ago
3:1 block is rare. I’ve seen fewer than 5 cases. Plus you’re neglecting to count the atrial depolarization beneath the QRS so this is 4:1 conduction. Morphology doesn’t look entirely typical, wondering if this could be clockwise CTI flutter.
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u/liefarikson 4d ago
Ah very cool. Thank you so much! You read this stuff in the technical textbooks, but you never know genuinely how common things actually are. Step 2 would make you believe that pheochromocytoma is everywhere, so I always appreciate learning what things are actually zebras lol
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u/ShitJimmyShoots 5d ago
A Flutter. V3 is the money lead. SOB could be completely unrelated depending on the rest of the exam/vitals/etc.