Advertisement

QRS Morphologies of Difficult Interpretation

  • Agnese Fioranelli
  • Enrico Paolini
  • Alessia Quaranta
Chapter

Abstract

ECG interpretation could be sometimes difficult and misleading.

We report here a case of left fascicular delays, called hemiblocks, that could possibly hide a structural heart disease or instead be completely meaningless.

In another example, we report Q waves in the inferior leads that could be pointless or consequence of a previous inferior myocardial infarction.

A simple clue to distinguish is to verticalize the heart axis through a deep inspiration; that could make Q waves’ disappearance in inferior leads.

Furthermore, a right bundle branch conduction pattern could sometimes implicate a differential diagnosis, between an incomplete RBBB and a Brugada syndrome.

In this chapter, we report three cases in which a correct ECG analysis may lead to the right diagnosis.

References

  1. 1.
    Elizari MV, Chiale PA. The electrocardiographic features of complete and partial left anterior and left posterior hemiblock. J Electrocardiol. 2012;45(5):528–35.CrossRefGoogle Scholar
  2. 2.
    Piccolo E, Raviele A. L’emiblocco anteriore sinistro 40 anni dopo rosenbaum. Rel.16/2008 6-02-2008. 2008. Available from: http://atti.centrolottainfarto.org/anno/2008/pdf/Piccolo 16_2008.pdf. Last Access 2018 Jan 27.
  3. 3.
    Ostrander LD. Left axis deviation: prevalence, associated conditions, and prognosis. Ann Intern Med. 1971;75(1):23.CrossRefGoogle Scholar
  4. 4.
    Yano K, Peskoe SM, Rhoads GG, et al. Left axis deviation and left anterior hemiblock among 8,000 Japanese-American men. Am J Cardiol. 1975;35(6):809–15.CrossRefGoogle Scholar
  5. 5.
    Biagini E, Elhendy A, Schinkel AFL, et al. Prognostic significance of left anterior hemiblock in patients with suspected coronary artery disease. J Am Coll Cardiol. 2005;46(5):858–63.CrossRefGoogle Scholar
  6. 6.
    Siontis GCM, Jüni P, Pilgrim T, et al. Predictors of permanent pacemaker implantation in patients with severe aortic stenosis undergoing TAVR: a meta-analysis. J Am Coll Cardiol. 2014;64(2):129–40.CrossRefGoogle Scholar
  7. 7.
    Brignole M, Auricchio A, Baron-Esquivias G, et al. ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Europace. 2013;15(8):1070–118.CrossRefGoogle Scholar
  8. 8.
    Goldberger AL, Goldberger ZD, Shvilkin AS. Goldberger’s clinical electrocardiography: a simplified approach. 9th ed. Philadelphia: Elsevier; 2017.Google Scholar
  9. 9.
    Mirvis DM, Goldberger AL. Electrocardiography. In: Zipes DP, Libby P, Bonow RO, et al., editors. Braunwald’s heart disease: a textbook of cardiovascular medicine. 11th ed. Philadelphia: W.B. Saunders; 2017.Google Scholar
  10. 10.
    Delewi R, Ijff G, van de Hoef TP, et al. Pathological Q waves in myocardial infarction in patients treated by primary PCI. JACC Cardiovasc Imaging. 2013;6:324.CrossRefGoogle Scholar
  11. 11.
    Goldberger AL. Pseudo-infarct patterns in the Wolff-Parkinson-White syndrome: importance of Q wave-T wave vector discordance. J Electrocardiol. 1980;13(2):115–8.CrossRefGoogle Scholar
  12. 12.
    Pirwitz MJ, Lange RA, Landau C, et al. Utility of the 12-lead electrocardiogram in identifying underlying coronary artery disease in patients with depressed left ventricular systolic function. Am J Cardiol. 1996;77:1289.CrossRefGoogle Scholar
  13. 13.
    Kucher N, Walpoth N, Wustmann K, Noveanu M, et al. QR in V1-an EKG sign associated with right ventricular strain and adverse clinical outcome in pulmonary embolism. Eur Heart J. 2003;24(12):1113–9.CrossRefGoogle Scholar
  14. 14.
    Bodenheimer MM, Banka VS, Helfant RH. Determination of lead III Q waves significance utility of deep inspiration. Arch Intern Med. 1977;137(4):437–9.CrossRefGoogle Scholar
  15. 15.
    Nanni S, et al. Inferior Q waves in apparently healthy subjects: Should we take a deep breath? An electrocardiographic, echocardiographic and cardiac magnetic resonance study. J Electrocardiol. 2016;49(1):46–54.CrossRefGoogle Scholar
  16. 16.
    Goldman MJ. Principles of clinical electrocardiography. Los Altos: Lange; 1988.Google Scholar
  17. 17.
    Agarwal AK, Venugopalan P. Right bundle branch block: varying electrocardiographic patterns. Aetiological correlation, mechanisms and electrophysiology. Int J Cardiol. 1999;71(1):33–9.CrossRefGoogle Scholar
  18. 18.
    Schamroth L. The 12 lead electrocardiogram. Oxford: Blackwell; 1989.Google Scholar
  19. 19.
    Schamroth L, Myburgh DP, Schamroth CL. The early signs of right bundle branch block. Chest. 1985;87:180.CrossRefGoogle Scholar
  20. 20.
    Mauric AT, Samani NJ, de Bono DP. When should we diagnose incomplete right bundle branch block? Eur Heart J. 1993;14(5):602–6.CrossRefGoogle Scholar
  21. 21.
    O’Neal WT, Qureshi W, Li Y, et al. RSR’ pattern and the risk of mortality in men and women free of cardiovascular disease. J Electrocardiol. 2015;48(3):430–3.CrossRefGoogle Scholar
  22. 22.
    Bayés de Luna A. Current electrocardiographic criteria for diagnosis of Brugada pattern: a consensus report. J Electrocardiol. 2012;45(5):433–42.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Agnese Fioranelli
    • 1
  • Enrico Paolini
    • 1
  • Alessia Quaranta
    • 1
  1. 1.Clinica di Cardiologia e AritmologiaUniversità Politecnica delle MarcheAnconaItaly

Personalised recommendations