A quick ECG from my mummy

Got sent this ECG by my Mum who is a kickass emergency nurse and midwife.

She saw a young man who came in after a syncopal episode.  Thoughts on the ECG?

Update October 17:

So had a few comments and thoughts on twitter and here people are pretty onto it with this one.

My thoughts:looking at the ECG,

Sinus rhythm rate of 60.

V1/V2 and maybe V3 have what i would agree look like Epislon waves. T waves are not inverted.

High voltage ECG but difficult to accertain in a skinny young male.

QTC is 390 but the QRS in V1-V3 is not widened.

So we have a young mane with syncope our concern is hypertrophic/arrthmogenic cardiac disease in this case ARVD (Arrhythmogenic right ventricular dysplasia)

First a bit more on ARVD,

ARVD is a genetic defect that causes fibro/fatty change in the myocardium. It predominantly effects the right ventricle.It has an incidence of  1/1000 with a male predominance, from 1/3 to 1/2 of cases are familial. For those working in Italy apparently it has a much higher incidence possibly as high as 40/1000. It is a major cause of cardiac death/sudden death in children and young adults.

The diagnosis is made Via ECG findings, Family history, ECHO +/- endomycardial biopsy

Diagnosis of ARVD: requires 2 major criteria and one minor.

Major Criteria

Minor Criteria

Touch more about Epsilon waves apparently can be caused by other diseases of the right ventricle, including right ventricular infarction, infiltration disease, and sarcoidosis which might also produce the pathological substrate required for production of epsilon waves.

Outcome of the case:

Patient was referred to the tertiary ED who happily took the patient. They were admitted under cardiology and patient had an ECHO which showed no concerning features! Bloods were all normal. Kept on telemetry and discharged home with follow-up. I am unsure if they are planning on going to Biopsy or not at this stage.

Comments

  1. Seth Trueger says:

    was it perhaps an exertional syncope? perhaps the young man was playing sports?

  2. When I saw those “blips” a the end of the QRS complexes the first thing that popped into my head was ARVD (arrhythmogenic right ventricular dysplasia). The rest of the pattern doesn’t quite fit though (no right-precordial T-wave inversion, no widening of the terminal portion of the QRS). Instead they look more like J-waves (Osborn waves), so I’m doing a bit more reading on them and their significance right now.

    At the moment I’m leading towards needing to rule-out some manner of hypertrophic cardiomyopathy in this patient. Young folks have the hardest ECG’s since most folks aren’t typically trained in their findings. I know I’m far from comfortable with them.

  3. V1/V2 have what could be epsilon waves, or they’re just more of the fractionated QRS / J-waves.

    Echo due to Q-waves out to V5/V6 and high voltage to rule out HCM/HOCM.

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