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Analyse this ecg and tell the pathology and axis deviation
analyse_media
ECG Analysis - Male, 57 years (23 Jan 2024)
Axis Deviation
Left Axis Deviation (LAD) is present, approximately -30° to -45°:
- Lead I: predominantly positive (upright R)
- Lead aVF: predominantly negative (rS pattern)
- Lead II: predominantly negative (rS pattern)
This pattern in the context of narrow QRS complexes is consistent with Left Anterior Fascicular Block (LAFB) - the left anterior fascicle of the bundle of His is not conducting normally, causing the electrical axis to shift superiorly and to the left.
Primary Pathology: Atrial Fibrillation (AF) with Controlled Ventricular Response
Evidence:
- No P waves in any lead - replaced by fine, irregular fibrillatory (f) waves, best seen in V1-V2
- Irregularly irregular R-R intervals (hallmark of AF)
- Ventricular rate: ~50-60 bpm - this is a "controlled" or rate-controlled AF (may suggest the patient is on rate-controlling drugs: beta-blockers, diltiazem, verapamil, or digoxin)
Additional Findings
| Feature | Finding |
|---|---|
| QRS duration | Narrow (<100 ms) - normal intraventricular conduction |
| ST segments | Isoelectric - no acute ischemia/injury pattern |
| T waves | Flat to mildly inverted in II, III, aVF (secondary to LAFB) |
| Precordial transition | Normal (V3-V4) |
| V5-V6 | Tall R waves, small/absent Q waves |
Summary of Diagnoses
- Atrial Fibrillation with controlled ventricular rate (~50-60 bpm)
- Left Anterior Fascicular Block (LAFB) causing Left Axis Deviation (-30° to -45°)
- No acute ST-elevation or STEMI pattern
- No right bundle branch block or left bundle branch block (QRS is narrow)
Clinical Note
The combination of AF + LAFB raises consideration of:
- Hypertensive heart disease (most common cause of both)
- Dilated cardiomyopathy
- Ischemic heart disease
- Valvular disease (especially mitral)
Rate control appears adequate, but anticoagulation status (CHA₂DS₂-VASc score) should be assessed to reduce stroke risk. Correlation with clinical history, echocardiogram, and thyroid function is recommended.
Disclaimer: This analysis is for educational purposes. Clinical decisions must be made by a licensed physician with access to the full clinical picture.
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Analysis of this ecg tell pathology heart rate axis deviation
analyse_media
ECG Analysis - 12-Lead (30 Dec 1972, 07:00:40)
Printed Machine Measurements
| Parameter | Value |
|---|---|
| Heart Rate | ~110 bpm (RR = 546 ms) |
| PR Interval | 136 ms |
| QRS Duration | 190 ms (severely prolonged) |
| QT / QTc | 336 ms / 455 ms (QTc borderline prolonged) |
| QRS Axis | -75° (machine) / -63° (handwritten) |
| T Axis | 65° |
| Paper speed | 25 mm/s, 10 mm/mV |
Axis Deviation
Extreme Left Axis Deviation (LAD): -63° to -75°
- Lead I: broad, tall, positive monophasic R wave
- Lead aVF: deep, wide QS pattern (negative)
- Lead II: deep, wide rS/QS pattern (negative)
This places the axis firmly in the upper-left quadrant, well beyond the -30° threshold for LAD. The degree of leftward shift (-75°) in the presence of LBBB indicates co-existing Left Anterior Fascicular Block (LAFB).
Primary Pathology: Left Bundle Branch Block (LBBB)
The QRS of 190 ms (normal <120 ms) is grossly prolonged. Lead-by-lead morphology confirms LBBB:
| Lead | Finding |
|---|---|
| I, aVL, V5, V6 | Broad, slurred, notched monophasic R waves (no septal Q) |
| V1, V2, V3 | Deep, wide QS complexes |
| V4 | Wide QS/rS pattern |
| aVR | Broad positive r/R wave |
This is the classic "M pattern" in V5-V6 and W pattern in V1 of LBBB.
Rhythm
Tachycardia at ~110 bpm - the baseline shows significant artifact/tremor. Whether this is sinus tachycardia with obscured P waves or Atrial Fibrillation with rapid ventricular response requires clinical correlation. The RR intervals are difficult to assess for regularity due to baseline noise.
ST-T Changes
All ST-T changes are discordant (opposite to the terminal QRS direction) - this is expected in LBBB and is secondary/physiological:
- V1-V4: ST elevation with upright T waves (opposite to the negative QRS) - secondary to LBBB
- I, aVL, V5-V6: ST depression + T-wave inversion (opposite to the positive QRS)
Important: The Sgarbossa criteria should be applied if acute MI is clinically suspected:
- ST elevation concordant with QRS (same direction) would suggest ischemia
- ST elevation >5 mm discordant may also be suspicious in the right clinical context
Summary of Diagnoses
- Left Bundle Branch Block (LBBB) - QRS 190 ms - new or old?
- Extreme Left Axis Deviation (-75°) - likely LBBB + Left Anterior Fascicular Block (LAFB) (bifascicular block pattern)
- Tachycardia ~110 bpm - sinus tachycardia vs. AF with rapid ventricular response
- QTc 455 ms - borderline prolonged (partly due to LBBB itself)
- Secondary ST-T changes consistent with LBBB (clinically rule out ACS if new LBBB)
Clinical Significance
New LBBB with tachycardia is a STEMI-equivalent until proven otherwise. If this is a new LBBB in a symptomatic patient, it warrants urgent evaluation for acute anterior MI. Correlation with prior ECGs, cardiac troponins, and clinical symptoms is mandatory.
Disclaimer: This is an educational ECG interpretation. All clinical decisions must be made by a licensed physician with full access to the patient's clinical context.
image.jpg
Analysis of this ecg tell pathology heart rate axis deviation
analyse_media
ECG Analysis - Furmistrov G.V., Male, 66 years (30 Dec 1972)
Printed Machine Measurements
| Parameter | Value |
|---|---|
| Heart Rate | ~110 bpm (RR = 546 ms) |
| PR Interval | 190 ms (normal) |
| QRS Duration | 136 ms (prolonged) |
| P Duration | 134 ms (prolonged) |
| QT / QTcB | 336 ms / 455 ms |
| P / QRS / T Axis | 65° / -75° / 60° |
| Handwritten axis | -63° |
| Paper speed | 25 mm/s, 10 mm/mV |
Axis Deviation
Extreme Left Axis Deviation (LAD): -63° to -75°
| Lead | Finding | Significance |
|---|---|---|
| Lead I | Tall broad qR | Positive - left-directed |
| Lead aVL | Tall broad R | Positive - superior |
| Lead II | Deep rS | Negative - confirms LAD |
| Lead III | Deep rS | Negative |
| Lead aVF | Deep rS | Negative |
Axis in the range of -63° to -75° is well past the LAD threshold (-30°), indicating marked leftward and superior deviation.
Primary Pathology: Left Bundle Branch Block (LBBB)
QRS duration = 136 ms (diagnostic threshold >120 ms). Classic LBBB morphology:
| Lead Group | Finding |
|---|---|
| V1-V4 | Deep, wide QS complexes with absent R-wave progression |
| V5, V6 | Broad, slurred, notched R waves without septal Q waves |
| I, aVL | Tall, broad monophasic R waves (qR pattern) |
| aVR | Deep QS/rS complex |
This is the hallmark "W" in V1 and "M" in V5-V6 pattern of complete LBBB.
Rhythm
Sinus Tachycardia at ~110 bpm
- P waves are present and precede every QRS (unlike the previous ECG)
- PR interval = 190 ms (normal range)
- RR interval regular at ~546 ms
Co-existing Left Anterior Fascicular Block (LAFB)
The extreme LAD of -75° in the setting of LBBB indicates the left anterior fascicle is also involved:
- rS in II, III, aVF + qR in I, aVL = LAFB pattern
- Combined with LBBB = Bifascicular block (left bundle branch + left anterior fascicle - though technically LBBB already implies bifascicular disease anatomically)
ST-T Changes
All discordant (expected with LBBB - secondary changes):
| Leads | ST Change | Reason |
|---|---|---|
| V1-V4 | ST elevation (discordant to deep negative QRS) | Secondary to LBBB |
| I, aVL, V5-V6 | ST depression + T inversion (discordant to positive QRS) | Secondary to LBBB |
Prolonged P Duration (134 ms)
P duration >120 ms suggests left atrial enlargement or intra-atrial conduction delay (also known as P mitrale). This may indicate underlying hypertensive or valvular heart disease.
Summary of Diagnoses
- Sinus Tachycardia - ~110 bpm
- Complete Left Bundle Branch Block (LBBB) - QRS 136 ms
- Extreme Left Axis Deviation (-75°) with features of Left Anterior Fascicular Block (LAFB) - bifascicular conduction disease
- Left Atrial Enlargement - P duration 134 ms
- Secondary ST-T changes consistent with LBBB (rule out acute ACS if new onset)
- QTc 455 ms - borderline prolonged (partly attributable to LBBB)
Clinical Significance
This ECG in a 66-year-old male with LBBB + extreme LAD + left atrial enlargement + tachycardia strongly suggests underlying hypertensive heart disease, dilated cardiomyopathy, or ischemic cardiomyopathy. If this LBBB is new in a symptomatic patient, it should be treated as a STEMI-equivalent and urgent evaluation is required.
Disclaimer: This is an educational ECG interpretation. All clinical decisions must be made by a licensed physician with full clinical context.
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