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Diagnosis
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ECG Interpretation
Standard: 25 mm/s, 10 mm/mV
Systematic Analysis
| Parameter | Finding |
|---|---|
| Rate | ~45-48 bpm (bradycardia) |
| Rhythm | Regular |
| P wave morphology | Negative/inverted in inferior leads (II, III, aVF); positive in aVR - consistent with retrograde/low atrial activation |
| PR interval | Short to normal |
| QRS duration | Narrow (~80-100 ms) |
| Axis | Left axis deviation |
| ST changes | ST depression in inferior leads; ST elevation in aVR |
| T waves | Inverted in inferior leads (II, III, aVF) and possibly lateral leads |
Diagnosis
Primary Diagnosis: Ectopic Atrial Rhythm (Low Atrial / Coronary Sinus Rhythm)
- Rate of ~45-48 bpm with a regular, narrow-complex rhythm
- P waves are inverted in leads II, III, aVF and upright in aVR, indicating the atrial impulse originates from a low atrial or junctional/coronary sinus focus rather than the SA node
- The short RP interval supports retrograde atrial activation
Secondary / Co-existing Findings to Consider:
-
Inferior ischemia/injury - ST depression and T-wave inversions in inferior leads (II, III, aVF) raise concern for inferior wall ischemia or a right coronary artery (RCA) territory event. ST elevation in aVR may indicate a proximal culprit.
-
Bradycardia - May represent sick sinus syndrome, high vagal tone, or drug effect (e.g., beta-blockers, calcium channel blockers, digoxin).
Clinical Correlation Required
- Symptoms: chest pain, syncope, dyspnea?
- Troponins / cardiac enzymes to rule out ACS
- Echo to assess wall motion abnormalities
- Medication review - any AV nodal agents?
- Consider right heart involvement if inferior STEMI: check lead V4R
ECG findings must always be correlated clinically (as stated on the tracing).
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