Is there any ischemic changes here. Deep q at lead II and III ?

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analyse_media

ECG Analysis

Here is a systematic read of this 12-lead ECG:

Basic Parameters

Heart rate: ~97 bpm (sinus rhythm)
Axis: Left axis deviation, approximately -67 degrees (per machine printout)
Intervals: QTc 349/442 ms, P/QRS/T axis -1/63 deg per the header

Regarding Your Specific Questions

Deep Q waves in II and III?

The deep negative deflections you are seeing in leads II, III, and aVF are best explained by Left Anterior Fascicular Block (LAFB), not a pathological Q wave from infarction. Here is why:

In LAFB, the initial septal activation goes inferiorly, then swings superiorly and to the left - this produces an rS pattern in the inferior leads (small r, deep S) and a dominant R in lead I/aVL
What looks like a "deep Q" in lead III is actually the deep S-wave of this rS pattern, or a QS/Qr complex from the redirected axis
Lead II shows a small initial r followed by a deep S - this is characteristic of LAFB, not infarction

Ischemic changes?

No acute ST elevation anywhere on this tracing
No ST depression to suggest subendocardial ischemia
No hyperacute T waves
No Wellens' pattern (no deep symmetric T-wave inversions in V2-V3)
T-wave inversion isolated to lead III is a normal variant, especially with left axis deviation

Summary

Feature	Finding
Acute STEMI	Not present
ST depression / subendocardial ischemia	Not present
Pathological Q waves (inferior MI)	Not confirmed - pattern consistent with LAFB
Wellens' / anterior ischemia	Not present
Rhythm	Sinus, ~97 bpm
Key finding	Left Anterior Fascicular Block (LAFB)

Bottom Line

This ECG does not show diagnostic signs of acute ischemia or infarction. The deep deflections in leads II and III are most consistent with LAFB (left axis deviation to -67°), which is a common mimicker of inferior Q waves.

Important caveats:

A single ECG cannot rule out ACS if the patient has active symptoms
Serial ECGs + high-sensitivity troponin remain essential if there is clinical suspicion
Comparison with a prior ECG is invaluable - if LAFB is new, that itself warrants investigation

What causes LAFB. Does it need to be referred

Reading File

Finding Sources

Searching PubMed

left anterior fascicular block prognosis management

Reading File

Here is a thorough breakdown based on authoritative textbook sources:

What Causes LAFB?

LAFB results from failure of conduction down the anterior fascicle of the left bundle branch. The anterior fascicle is thin and has a single blood supply (from the LAD), making it vulnerable.

Causes (from most to least common):

Category	Specific Causes
Degenerative	Fibrosis/sclerosis of the conduction system (Lev's/Lenègre's disease) - most common in elderly
Coronary artery disease	LAD territory ischemia or infarction
Structural heart disease	Hypertensive heart disease, aortic valve disease, cardiomyopathy
Post-procedural	After TAVR (transcatheter aortic valve replacement), cardiac surgery
Infiltrative/inflammatory	Sarcoidosis, amyloidosis, myocarditis
Normal variant	Found in ~1% of otherwise healthy adults

As Goldman-Cecil Medicine states: "Left anterior fascicular block is found in about 1% of otherwise healthy adults. However, it can be associated with degenerative disease of the conduction system, myocardial fibrosis, coronary artery disease, and structural heart diseases."

Does It Need Referral?

It depends on the clinical context. LAFB alone is generally benign, but the key question is: why has it appeared, and is it new?

No urgent referral needed if:

Isolated, incidental LAFB on routine ECG
Patient is asymptomatic
Known chronic finding on prior ECGs
No structural heart disease on echo

Referral IS warranted if:

It is NEW - a new LAFB always warrants investigation for an underlying cause (ischemia, cardiomyopathy). Get a prior ECG for comparison first.
Patient has symptoms - chest pain, dyspnea, syncope, or presyncope. Syncope with fascicular block is a red flag and warrants cardiology referral for pacemaker consideration.
Bifascicular block - if LAFB is combined with RBBB (right bundle branch block), this is bifascicular block and carries a significantly higher risk of progression to complete heart block. Referral is recommended.
LAFB + prolonged PR interval - this is effectively trifascicular block and has a high risk of progressing to complete AV block; prophylactic pacemaker is often placed.
Underlying structural disease suspected - refer for echocardiography and stress testing.

Recommended Workup (before or during referral):

Compare with prior ECG - is this new or old?
Echocardiogram - assess LV function and structural disease
Stress test - rule out ischemia as the cause
Troponin - if new and symptomatic
Cardiac MRI - if infiltrative cardiomyopathy is suspected

Bottom Line for This Patient's ECG

The LAFB here (axis -67°) in an otherwise unremarkable tracing, with no acute ischemia and no bundle branch block, is a relatively common finding. The immediate priority is:

Is this new or old? (check prior ECGs)
Does the patient have symptoms (syncope, chest pain, exertional dyspnea)?
Is there any structural heart disease?

If all three are absent and it is a known chronic finding - monitoring without urgent referral is reasonable. If any of those are present, or if this is a new finding, cardiology referral is appropriate.

Goldman-Cecil Medicine, p.565
Harrison's Principles of Internal Medicine 22E, Chapter 247

Treatment LAFB

Finding Sources

Reading File

Treatment of LAFB

The core principle, directly from Goldman-Cecil Medicine: "Treatment for intraventricular conduction delays is targeted at any underlying cause. However, rhythm-specific treatments are sometimes indicated."

Step 1 - Treat the Underlying Cause

This is the primary treatment strategy. If you find and fix the cause, the block may resolve or at least stop progressing.

Underlying Cause	Treatment
Coronary artery disease / ischemia	Revascularization (PCI/CABG), antiplatelet, statin
Hypertension	Antihypertensives
Heart failure	Guideline-directed HF therapy (ACEi/ARB, beta-blocker, diuretic)
Aortic valve disease	Valve repair/replacement
Electrolyte disturbance (e.g. hyperkalemia)	Correct the electrolyte
Drug-induced (class I antiarrhythmics, TCAs)	Withdraw the offending agent
Infiltrative disease (sarcoid, amyloid)	Disease-specific therapy

Step 2 - Rhythm-Specific Interventions (when indicated)

There is no medication that treats LAFB directly. Pacemaker therapy is the only rhythm-specific option, and it is only indicated in specific scenarios:

When a Pacemaker IS Indicated:

Scenario	Action
LAFB + syncope/presyncope	Permanent pacemaker preferred over implantable cardiac monitor (Grade A evidence: Sheldon et al., JACC 2022)
Bifascicular block (LAFB + RBBB) + PR prolongation	Prophylactic pacemaker - high risk of progression to complete heart block
LAFB + acute MI	Pacemaker placement if bifascicular block with PR prolongation
LAFB + heart failure	If progresses to complete LBBB, may need biventricular pacing (CRT)

When a Pacemaker is NOT Indicated:

Isolated LAFB, asymptomatic, no structural disease
LAFB + RBBB (bifascicular) without symptoms or PR prolongation - pacing not prophylactically indicated just for the block alone

Step 3 - Monitoring

Even without pacemaker indication, ongoing surveillance is important:

Rhythm monitoring (Holter/event monitor) - if PR interval is prolonged, alternating blocks present, or any lightheadedness/presyncope
Echocardiogram - baseline LV function assessment
Stress test - rule out ischemia
Cardiac MRI - if infiltrative cardiomyopathy suspected
Serial ECGs - watch for progression to bifascicular or trifascicular block

Summary Flowchart

LAFB found on ECG
      ↓
Is it NEW?  ──YES──→  Investigate urgently (troponin, echo, stress test)
      ↓ No
Any symptoms? (syncope, presyncope, chest pain, dyspnea)
      ↓ YES → Refer cardiology; consider pacemaker if syncope
      ↓ No
Is RBBB also present (bifascicular block)?
      ↓ YES → Refer cardiology; pacemaker if + PR prolongation or syncope
      ↓ No
Isolated, asymptomatic, chronic LAFB
      ↓
Monitor: echo + stress test + serial ECGs

For this patient's ECG (isolated LAFB, axis -67°, no acute ischemia), no pacemaker is needed unless clinical context reveals symptoms or structural disease.

Goldman-Cecil Medicine, p.565-566
Miller's Anesthesia 10e, p.3923-3924

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