James A. Reiffel presented an enigmatic ECG (Circulation. 2016;134:499. DOI: 10.1161/CIRCULATIONAHA.116.023662)
The patient is a 52-year-old male corporate executive who comes to the office as a new patient, having just been relocated by his company. He gives a histy of smoking (1 pack per day for 25 years), hyperlipidemia, and hypertension, and he currently is taking a statin, an angiotensin receptor blocker, a β-blocker, and a daily aspirin. He denies any history of chest pain or dyspnea, other than 2 days of mild chest fullness with slight shortness of breath 2 months earlier during a vacation to Vail, Colorado, after a particularly stressful period at work. On return home, he saw his internist who told him, after obtaining a confirmatory echocardiogram, that he had experienced a myocardial infarction, but that his heart function was near normal. At that time, his medications were adjusted to his current regimen. He has no previous medical records with him, but denies any other recent or remote illnesses. An ECG is obtained and is shown (Figure below). What is your interpretation?
Author answer: http://circ.ahajournals.org/content/134/7/567
The ECG has 2 notable abnormalities. The first is mirrorimage
dextrocardia, a congenital abnormality, as indicated by the frontal plane
axis coupled with the precordial lead pattern. In isolation, dextrocardia with situs
inversus confers no additional cardiac risk and has a prevalence of 1 to 2/10000,
whereas 3% to 10% have been reported to have concomitant congenital heart
disease.
1 Typical dextrocardia with situs inversus has a characteristic rightward
axis with inverted P, QRS, and T waves in lead I and a tall R wave in lead AvR when
uncorrected leads are used, and a lack of precordial R:S progression as well, plus
a decrease in QRS voltage as the leads move from V1 to V6.
2 Moreover, the pattern of lead V1 resembles a normal V2, and V2 resembles a normal V1.
First would have to be sure that the ECG was not taken with inverted cables.
The clue is the inverse progression of precordial leads associated with a pattern of inverted Right arm/Left arm leads. A double error of misplacing peripheral and precordial leads is very unlikely (even if possible!), thus suggesting dextrocardia.
This ECG very similar for patiens with dextrocardia and Kartagener syndrome:
1. Negative P wave and QRS comle[ in I and aVL leads, positive P in aVR
2. maximal QRS (RS type) in V1,
3. Progressive decreasing of RS amlpitude from V1 to V6
4. Negative T wave in V4-6
Possible recent anterior myocardial infarction. Repeat Echocardiogramm to exclude Pericarditis. Most probably wrong ECG lead positioning.
Dear Eliana inversion of the P wave not could explaine MI of any localisation. Best regards.
Dear colleagues, thank you all for your interest and attention.
Best regards.
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