A 32-year-old woman has an electrocardiogram (ECG) as part of a workup for epigastric burning and reflux symptoms, which she has been experiencing for one year. The ECG (Figure 1) demonstrates T wave changes and Q waves suggestive of anterior and inferior infarct, as well as left ventricular hypertrophy and left atrial abnormality. She denies any history of cardiac disease and has no history of hypertension. She is on no medications other than oral contraceptives. She denied chest pain, shortness of breath, dyspnea, and walks 15 minutes per day without difficulty.
Figure 1
After reviewing the ECG (Figure 1), which of the following do you conclude?
Show Answer
The correct answer is: B. Possible congenital heart disease; recommend transthoracic echocardiogram.
The ECG is notable for a short PR interval (80 ms), QRS prolongation (130 ms) with slurring of the initial QRS forces manifesting as positive delta waves in leads V5, V6, I, and aVL, and QS waves (with negative/isoelectric delta waves) in V1, V2, III and aVF. These are consistent with ventricular pre-excitation, from an early ventricular activation down accessory pathway. The Q waves on this ECG represent pre-excitation that begins in the right sided postero-septal region; the QRS vector thus travels away from leads V1, III and aVF, creating a negative initial deflection that results in an infarction pattern. Accessory pathways are often seen as isolated cardiac abnormalities, but one must remember that they are also associated with congenital heart disease, most notably Ebstein anomaly, where such pathways are seen in 25% of cases, typically right-sided.
Answer A is incorrect as the pattern is not from a true myocardial infarction, and a history consistent with non-ischemic chest pain is provided. A stress echocardiogram could detect an Ebstein anomaly; however, in the absence of ischemic symptoms, a dedicated resting transthoracic echocardiogram would provide the same information at a lower cost.
Answer C is incorrect. The patient does have a history suggesting non-cardiac chest pain; however, the ECG finding is specific for ventricular pre-excitation, and the recognition of this would lead to appropriate screening with echocardiogram as noted.
Answer D is incorrect. The ECG pattern does not reflect ST segment elevation suggestive of injury pattern or acute myocardial infarction in a specific vessel distribution with associated reciprocal changes in opposing wall usually seen with acute injury pattern.
Video 1 shows the apical 4-chamber view demonstrating apical displacement of the tricuspid valve and resulting "atrialization" of the right ventricle typical of Ebstein anomaly.
Video 1
References
Webb, GD, Smallhorn, JF, Therrien, J, Redington, AN. Congenital Heart Disease in Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 10th edition, Philadelphia: Elsevier Health Sciences.;2011.
Al-Khatib SM, Arshad A, Balk EM, et al. Risk Stratification for Arrhythmic Events in Patients With Asymptomatic Pre-Excitation: A Systematic Review for the 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia. A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2016;67:1624-1638.
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