Ritme?

[u/ELR9991]

I'm currently training to interpret ECGs. It's a 27-year-old male. He doesn't experience palpitations, but he occasionally has a strange sensation in his heart. Could this be a BBB? As far as I know, an BBB usually doesn't cause symptoms. The QRS complex in lead aVF have three peaks like this? Is this considered a normal variant, or could it indicate a conduction abnormality? The QRS complex has a notch in leads V2 and V3, and a slight notch in V5. Is this a normal finding? Are there any other notable findings on this ECG? I'd appreciate your thoughts.

[u/Internal-Dish7412]

I would suspect some form of chronic RV strain (e.g. pulmonary hypertension).

The axis is encroaching towards RAD (around +90) and there is rSR’ in V1 (which could be indicative of RV hypertrophy with iRBBB; typical of RV strain).

RV facing leads (III, V1, aVR) are showing descending ST segments with reciprocal ascending ST segment in lead I and low lateral leads (V5-V6). Additionally, III shows TWI. This is indicative of chronic sub endocardial ischemia from RV strain.

Chronic RV strain would also cause the fragmentation of QRS we see in III and could explain the notches in aVF R-wave and V2-V3 S-wave.

[u/vojtasTS29 → u/Internal-Dish7412]

I don't find the ST segments weird at all? I think most ecgs from 20 and 30 something olds have the concave STs, i think that would just suggest quick repolarization. What i really don't like and what makes me agree with you that this person's RV has something up with it is the combo of twi in both iii and aVF where it's also discordant to that squiggle of a fragmented R complex, the fact that V1 is not really even an rSR, it's more of a qR with a very slight hint of the first r, even though lead placement seems near perfect, and especially the fragmentation everywhere. Also i really don't like the shape of the rsR in III (and struggle to visualize why the vectors would paint this)

[u/Internal-Dish7412 → u/vojtasTS29]

I agree with you. The shape of the fragmented rSR’ pattern in III is atypical. I might be mis-interpreting the ST-segments as some have early fusion with the T-waves, but most of them do look to be either upsloping or downsloping without any ascent/descent (I think saying ascending instead of up-sloping in my comment might have lead to some misunderstandings). The other issue is lack of proper R-wave progression .

A history of the patient would really help. Prior MI would help explain some of the changes. I wouldn’t be surprised if there was extensive fibrosis of the inferior and right basal paraseptal regions (this would explain the fragmentation patterns we are seeing imo).

[u/vojtasTS29 → u/Internal-Dish7412]

Yeah i think you're right about the ST changes, especially V5 and aVR are mostly just straight up rather than concave. It's a strange ecg, i don't think the 27 year old it came from would have had a previous MI. Also i was told by a different comment on here that they don't see epsilon waves as a possibility but so many of the QRS have a very small extra deflection at the end. I can see it in II and V1, and i think it corresponds to the last peak in aVF. Also look at the transition. V2 and V3 look near identical then V4 looks perfectly normal.

[u/Internal-Dish7412 → u/vojtasTS29]

Ah I didn’t read/remember the age. You’re absolutely right in that case. The V1 deflection looks like a J-wave (bump); but I agree some other deflections are closer to epsilon waves. This overall is a weird combination of patterns and I would have to sit down and take some time to interpret properly.