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Practice ECG 19
This ECG shows evidence of biatrial enlargement. Note the large terminal forces of the P wave in V1. Remember, this is one of the criteria for LAE. Now, note that the initial deflection of the P wave is taller in V1 than in V6, which suggests RAE. What other chamber is enlarged? Well, there are three criteria present for LVH. First, the sum of the R wave in V5 and the S wave in V1 is more than 35 mm. Second, the R wave in aVL is more than 11 mm. Finally, the R in lead I is more than 12 mm.
Do the ST segments look normal to you? There is some depression of the segments in I, II, aVF and V3 to V6, but the segments are also shaped differently. Remember the ice cream scoop? This scooped-out ST segment is classic for digoxin effect. You should always check a digoxin level on any patient who presents with cardiac symptomatology and the scooped effect on the ST segments. This is a good habit to get into; it will save you and your patient considerable heartache.
The final comment that we will make about this ECG is that the QT interval is prolonged. This may be caused by the LVH, but in the presence of digoxin you need to think about the rest of the differential-drug effect, electrolyte abnormalities, and so on.
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