ECG Analysis

• ID: 32670 | Name: Saran | Male, 26 years
• Date: 27-04-2026, 02:05:48 PM
• Institution: Medical Trust Hospital, Kayankt
• Machine: BPL Cardiart 9108, Glasgow scoring

Automated Measurements

Manual Review of the Tracing

• Rate ~92 bpm — upper-normal/mild sinus tachycardia
• Regular rhythm; P waves visible before each QRS — normal sinus rhythm

• 100 ms — this is SHORT (normal 120–200 ms). A PR < 120 ms raises the question of a pre-excitation syndrome (WPW/accessory pathway) or an accelerated junctional/AV nodal pathway (LGL syndrome). However, at 100 ms the QRS is narrow (86 ms) and there is no visible delta wave on the tracing — the machine did not flag it, but this warrants attention clinically.

• 86 ms — narrow, normal morphology
• No bundle branch block pattern
• No pathological Q waves seen
• Axis ~67° — normal axis

• No ST elevation or depression visible
• T waves appear upright in I, II, V4–V6
• T-wave inversion not apparent in lateral leads

• 421 ms — borderline upper normal (normal <440 ms in men; <460 ms in women). Not prolonged.

• RV5 + SV1 = 1495 + 1126 = 2621 mV (2.621 mV)
• Cornell criterion for LVH: >2.8 mV in men (SV3 + RaVL), Sokolow-Lyon: SV1 + RV5 >3.5 mV → 2.621 mV is below Sokolow-Lyon threshold — no voltage criteria for LVH

Key Finding to Investigate

Short PR interval (100 ms) in a 26-year-old male is the most clinically relevant finding. In a young patient, this must be correlated with:

• Symptoms: palpitations, syncope, pre-syncope
• Presence or absence of delta waves (slurred upstroke of QRS)
• If delta waves are present → Wolff-Parkinson-White (WPW) syndrome — risk of SVT and rarely sudden cardiac death via AF with rapid conduction
• If narrow QRS with no delta wave → consider Lown-Ganong-Levine (LGL) pattern or a normal variant

Summary

Clinical Recommendation

1. Assessed for palpitations, pre-syncope, or exercise-induced symptoms
2. Tracing reviewed by a cardiologist specifically for delta waves (a standard 12-lead may miss subtle pre-excitation)
3. If symptomatic → refer for electrophysiology evaluation
4. If asymptomatic and no delta waves confirmed → serial follow-up ECGs

⚠️ Disclaimer: This is an educational ECG interpretation only and does not constitute a clinical diagnosis. All ECG findings must be correlated with the patient's clinical history and reviewed by a qualified physician.

Updated Clinical Assessment: Symptomatic Short PR in a 26-Year-Old Male

The Clinical Picture

Mechanism — What Is Happening

1. Short PR — conduction begins via the fast AP, bypassing the delay at the AV node
2. Delta wave — slurred upstroke of the QRS from early ventricular activation
3. Risk of tachyarrhythmias — the AP can form a re-entry circuit (AVRT), and in AF with fast AP conduction, ventricular fibrillation and sudden death can occur

"Patients with preexcitation who have symptoms of arrhythmia are at risk for developing AF and sudden death if they have an AP that allows rapid antegrade conduction. The risk of cardiac arrest is in the range of 2 per 1000 patient-years." — Harrison's Principles of Internal Medicine, 22e

"Approximately 25% of APs causing preexcitation allow minimum R-to-R intervals of <250 ms during AF and are associated with a higher risk of inducing ventricular fibrillation and sudden death." — Harrison's, 22e

Why the ECG May Look "Normal" Here

• The AP is concealed (conducts retrograde only — no delta wave in sinus rhythm)
• Preexcitation is intermittent
• AP location minimises QRS distortion (e.g., posteroseptal)

Differential Diagnosis of Short PR + Palpitations + Pre-syncope

Management Pathway

Immediate Steps

1. Holter monitor / event recorder — document the tachyarrhythmia during symptoms
2. Repeat 12-lead ECG looking carefully for delta waves in all leads, especially V1–V4 and inferior leads
3. Echocardiography — rule out structural heart disease (Ebstein anomaly is associated with WPW in ~10% of cases)
4. Refer urgently to Cardiologist / Electrophysiologist

Definitive Evaluation

• Electrophysiology Study (EPS) — gold standard
  • Confirms presence and location of AP
  • Assesses antegrade refractory period of AP (short refractory period = high SCD risk)
  • Can proceed directly to catheter ablation

Definitive Treatment: Catheter Ablation

"Catheter ablation of the accessory pathway is recommended in patients with AVRT and/or preexcited AF." — Fuster & Hurst's The Heart, 15e (citing AHA/ACC/HRS 2015)

• Curative in >95% of patients
• Low complication rate
• Eliminates need for lifelong antiarrhythmic drugs
• First-line therapy for symptomatic WPW in a young patient

What to AVOID Until Evaluation

Red Flags Requiring Emergency Assessment

• Rapid, irregular wide-complex tachycardia → preexcited AF → emergency DC cardioversion
• Syncope (not just pre-syncope) → treat as high-risk, immediate cardiology review
• HR >200 bpm during tachycardia → suggests short AP refractory period

Summary for the Treating Clinician

⚠️ This analysis is for educational purposes. Clinical management must be directed by the treating physician with full access to the patient. — Harrison's Principles of Internal Medicine 22e; Fuster & Hurst's The Heart 15e

In the context of WPW (this patient):

1. Atrial fibrillation (AF) develops — common in WPW patients
2. The accessory pathway (AP) conducts the rapid atrial impulses directly to the ventricles, bypassing the AV node (which normally acts as a brake)
3. Ventricular rate can exceed 300 bpm
4. This degenerates into Ventricular Fibrillation (VF) — the heart quivers instead of pumping
5. Cardiac arrest → death within minutes if not defibrillated

Why it matters for this 26-year-old:

• SCD incidence in WPW = 0.15–0.39% lifetime risk (low, but not zero)
• In a symptomatic young patient (palpitations + pre-syncope), the risk is higher than in asymptomatic individuals
• It can be the first manifestation — meaning the patient may have no warning before cardiac arrest
• Catheter ablation eliminates this risk entirely — which is why it's Class I (strongly recommended)

Bottom line: