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ECG of the week #19: 75 year-old with sudden shortness of breath – what’s the cause of wide complex tachycardia?

Test yourself with this week’s ECG case. Then scroll down for a structured step-by-step interpretation and clinical pearl.

Clinical Scenario

A 75 year-old presented with acute shortness of breath and diaphoresis.

ECG

Question

What’s the cause of the wide complex tachycardia?

ECG Analysis

Heart rate/rhythm: sinus tachycardia
Electrical conduction: RBBB
Axis: left axis from LAFB
R-wave progression: early R from RBBB, late S from LAFB
Tall/small voltages: normal
ST/T: concordant STE V2, hyperacute T V3-4, inferior STD reciprocal to subtle high lateral

Answer

Sinus tachycardia with bifascicular block with acute LAD occlusion.
Cath lab activated: 80% left main and 90% proximal LAD occlusion

Clinical Pearl

Acute bifasicular block is a very high-risk pattern from left main or proximal LAD occlusion, and can be accompanied by only subtle concordant STE and hyperacute T waves

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