Question 15.1
A 60-year-old male is complaining of breathlessness of sudden onset two months previously.
There is no associated chest pain.
What are the abnormalities on the ECG and what is the likely diagnosis? (25 % marks)
College answer
Q waves in leads V1-V4 (Previous MI?)
Elevated ST segments and inverted T waves in V2-V5
Inverted T waves in aVL
Likely diagnosis is left ventricular aneurysm
Examiners Comments:
Many candidates appear to have examined the ECG, drawn a conclusion and then retrofitted findings to support that. Confabulation in answers was common. Acceptance in marking was made of relatively amorphous answers (e.g. "anterior" as opposed to specific leads) but even with this, lack of specificity was common. Many candidates ignored the highly pertinent history that was given, showing a lack of clinical context/Bayesian thinking.
Discussion
This image was shamelessly stolen from LITFL, where - one can be reasonably sure - the examiners also turn when they Google for ECG images. This one comes from the specific entry on LV aneurysm
For the record, the ECG features listed by LITFL are as follows:
- ST elevation seen > 2 weeks following an acute myocardial infarction.
- Most commonly seen in the precordial leads.
- May exhibit concave or convex morphology.
- Usually associated with well-formed Q- or QS waves.
- T-waves have a relatively small amplitude in comparison to the QRS complex (unlike the hyperacute T-waves of acute STEMI).