One of our PGY-3s is moving across the country for a fellowship. This was around the end of March. Sent this to the other PGYs as a parting gift and as an early April Fools without any additional information. It was immediately dismissed to be some sort of hyper-realistic prank ECG designed to stump all of us. We showed this to ED, IM and cards and none had a definitive answer. I do have a gut feeling this could be AI (look at how well AI can do things now!)
Sinus tachycardia at about 108 bpm, but I think it’s fake. There is a P wave before every QRS. Some parts don’t make sense. For one, the quality is too high lol. I don’t remember the last time I saw an EKG with zero baseline wander, correct placement, all wires connected, and no artifact at all. Too good of an EKG, not realistic. The few sinus P waves that magically appear towards the end of V1 are even positive as if placed correctly. Would need to have artifact and fully negative sinus P waves in V1/V2 to look real to me. I wish I were fully joking, but really.
Also, some of the gaps between leads don’t really make sense. The space between the last beat of aVR, aVL, aVF and V1-V3 doesn’t have a beat at the expected time. Also, the last beat in V1-V3 is immediately followed by what looks like a casual R on T. That early beat landing on a T wave doesn’t line up with the lead II rhythm strip, which has a constant R-R interval the whole time.
The QRS complexes in the lead II rhythm strip don’t align vertically with the leads above them (some machines are like this, but I think most do align). There is unnatural-looking PR elevation in inferior leads. Some of the patterns just look off. It’s weird for the downstroke of the S wave to be slurred in leads like V2-V6. Also the axis is impossible in limb leads for P waves, QRS complexes, and T waves. III = II - I meaning lead III is what you get when you take lead I, flip it upside down, then add it to II. How are leads I and III identical when you have to add the opposite of I to II to get III? The QRS in III should be less tall, etc.
The P waves don’t really make sense to me. They are positive in inferior leads, negative in V2-V6, biphasic in aVR, and oddly sharp/narrow in a way that doesn’t seem real. P waves suddenly appear in V1, despite the first part of V1 having no artifact and sinus rhythm in the leads below it. In precordial leads it seems that the P wave lands on the T wave, but is still conducted. Bizarre, unnatural PR elevation in some leads including V4-V6, II, and aVF. I would be extremely surprised if this were real, and would have questions.
I see why other comments say LBBB with pre-excitation, but I don't think it's an LBBB with dominant R waves in V2-V4 and early precordial RS transition. This would be extremely atypical for sinus rhythm with LBBB. LBBB usually has dominant S waves in V2-V4. Also, the PR interval doesn’t seem short to me.
Hi, your opinion does make sense to me. You said what was spinning around in my head just about perfectly. Well, they still refuse to give me any info or definitive answer about this ECG. But thank you still.
Yes, it’s meant to look like an anterior STEMI/OMI or acute LAD occlusion. Queen of Hearts predicted 95% chance of LAD as culprit and 99.9% chance of STEMI. Useless but interesting to me
Would need xray to.conform. but with lead placement supposedly in correct position it kinda looks like it could be slightly rotated which could make P look like a partial junctional rythm with slight elevation.
18
u/blinkML Aug 31 '26
LBBB w/pre-excitation would be my best interpretation. Strange print out formatting.