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Quote:
Originally Posted by Shrub
I'm unsure of how to explain this.
The qrs complex looks small in amplitude to me which I think means incomplete depolarization along with the long qt syndrome. I'm thinking a partial occluded coronary artery.
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Low QRS amplitude can have a bunch of different causes including ischemia/infarction. It can also be caused by anything ranging from Addison's disease to cardiac tamponade to obesity. Usually the criteria is 5mm in the limb leads and 10mm in the precordials. I can see what you are saying in leads II, and V6 which are right on the edge, but the amplitudes in the other leads are pretty decent. I would be hesitant to read too much into just those two leads but its certainly reasonable to think about.
ischemia can absolutely be a contributor to long QT.
When we're looking for ischemia or infarction, the first place we look is the ST segments and then the T waves. I've zoomed in a bit and highlighted some ST segments here and while this is not quite meeting STEMI criteria I find it very concerning that this patient has ST elevation in two contiguous leads (III, AvF) with reciprocal changes in I and AvL. This pattern is suggestive of possible inferior MI. We're not quite a millimeter, so I may not be activating the cath lab just based on this EKG, but its concerning. The elevation in AvR is also potentially concerning for left main disease as we're right around a millimeter. AvR isn't as specific as traditional STEMI criteria and can be a marker for subendocardial ischemia, so again, not spinning up the cath lab yet but worth a look.
Differential:
Long QT (QTc = 652)
Acute Coronary Syndrome
Hypertrophic Cardiomyopathy
Overdose, especially TCA
MVP -> Arrhythmia
In addition to the highlighted ST segments I've attached a highlighted version of the ECG pointing out some features. Does this suggest one last differential item to anyone?