VEB Revealing Old Infarction

Report:

Sinus rhythm

Atrial bigeminy

VEB

LVH with ST/T changes

Old anterior infarction

Comment:

A VEB can at times show infarctional Q waves not visible in normal complexes. This holds for QR and similar morphologies, but not the QS complexes44. In this case, V1-3 VEB reveals the old anterior infarct the patient was known to have 23 years previously.

There’s also poor R wave progression and small anterior forces in the precordial leads; LVH could account for the former, but not for the latter, especially in V5-6. Poor R wave progression is a timid way of hinting at anterior infarction; it’s rarely useful as a report item in its own right45.

The overall rhythm is bigeminal. On first impression this is due to 3:2 SA exit block, since all the P waves look alike. Alike, but not the same: P-terminal force is more sharply incised in the premature P’ waves than in the preceding sinus P waves. This persisted, now easier to see in lead 2 rhythm strip (60a).

60a.

61. 69 year old man with angina pectoris and stable, but very abnormal, ECG.