A Grossly Abnormal Electrocardiogram with Multiple Abnormalities

Correspondence: David H Spodick, MD, DSc, FACC, Medical Service/St Vincent Hospital, 123 Summer Street, Worcester, MA, 01608. E:

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A 67-year-old male outpatient with quiescent coronary disease and treated systolic hypertension (see Figure 1). Dominant sinus rhythm with ectopic atrial beats (AEB), not always premature, denoted by abnormal P waves in beat numbers 2, 4, 6, 8, 10, and 11. The single ‘rhythm strip’ of lead V1 fails to show corresponding P wave changes (except beat 11), but P V1 changes grossly on the final two beats, which are presumably of sinus origin (P in V6 looks like P in lead I). Interatrial block (IAB: wide, bifid P waves) in leads I, L, and V4–V6) corresponds to P-terminal force (Ptf), indicating left atrial enlargement in V1 and V2: a biphasic (+−) P with its terminal negativity (− area) equal to or greater than one square millimetre. P-pulmonale in lead II (single-peaked P, height over 2.5mm) reflected in lead III, but somehow lost in beat 2 of aVF, raising a question of that beat being ectopic (like its preceding and succeeding P-waves) since the last P in aVF (where it joins lead V3) is a P-pulmonale. There is also left deviation (to −30 degrees) of the QRS axis as well as left ventricular hypertrophy (LVH) by two sets of voltage criteria: Cornell (S V3 + R aVL over 28mm) and Sokolov–Lyon (R V6 + S V1 over 35mm) with strain (asymmetrically inverted T waves) in leads with dominant (here, pure) R waves. Normal septal q waves (sq), sometimes lacking in left ventricular hypertrophy (LVH), are seen in leads I and V6, their customary locations.