ECG Challenge: Abdominal Pain and Diarrhea in a Heart Disease Patient

Philip J. Podrid, MD

Disclosures

October 22, 2020

The correct diagnosis is sinus rhythm, LVH, and normal T waves (Figure 2).

Figure 2. Courtesy of Dr Podrid.

Discussion

The ECG shows a normal P wave (+) before each QRS complex with a stable and normal PR interval and a stable PP interval with a rate of 60 beats/min. This is a normal sinus rhythm.

The QRS complex is narrow and the axis is normal. The QRS complex in lead V2 shows a deep S wave ([) and there is a tall R wave in V5 (]). The voltage in these two leads is 45 mm, consistent with LVH. There is slight J point and ST elevation in leads V2-V4 (↓), consistent with early repolarization that is probably due to LVH.

The T waves in leads V3-V5 are tall and peaked, but they are asymmetric (┴) and therefore have a normal morphology — ie, the upstroke is slower than the downstroke. That they are tall and peaked is probably a result of LVH. In contrast, hyperacute T waves caused by hyperkalemia (systemic or localized as with an acute myocardial infarction) are not just tall and peaked but they are also symmetric in their upstrokes and downstrokes.

Philip Podrid, MD, is an electrophysiologist, a professor of medicine and pharmacology at Boston University School of Medicine, and a lecturer in medicine at Harvard Medical School. Although retired from clinical practice, he continues to teach clinical cardiology and especially ECGs to medical students, house staff, and cardiology fellows at many major teaching hospitals in Massachusetts. In his limited free time he enjoys photography, music, and reading.

You can follow Dr Podrid on Twitter @PPodrid

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