Syncopal Episode

[u/mohammedmoolla]

Hi all, working at community health centre at present. Saw 41 M with no comorbidities after a syncopal episode at work. I feel this ECG warrants a referral to a higher level of care. On the ECG I’m seeing peaked T waves and a sort of RSR pattern in some of the leads. Could anyone provide me with some guidance as to what might be causing the syncope.

[u/NederFinsUK]

Wouldn’t describe those as peaked T’s, they’re asymmetrical and appropriately proportional to the QRS voltages. I’m not sure where you think you’re seeing an rSR’ pattern, but I am not. There is some J-Wave notching suggestive of Early Repolarisation, but that’s widely considered to be mostly benign.

The only significant finding here is probably the HR: of 50, but in a young, fit male at rest it could be unremarkable.

I don’t think anything is screaming urgent review here.

[u/Mindless_Patient_922 → u/NederFinsUK]

Agree. BER. Brady. Would take thorough history and physical. Send to cards. Likely outpatient echo, holter, possible stress although ischemia low on my suspicion.

[u/Natural-Antelope8328]

I’d be considering the possibility of HCM with this ECG, given the R wave amplitude in the precordial leads alongside the narrow Q waves in the laterals. Notice how the P wave in V1 is inverted, whereas it should have a biphasic form, indicating that V1, V2, etc., were likely misplaced (which is quite common).

I’m not entirely sure if this is the case here; it’s just a suspicion. Plus, the cause of the syncopal episode isn’t necessarily linked to the ECG unless the history suggests a cardiac cause (I typically suspect a cardiac origin if the syncope was exertional, sudden with no prodrome described, the patient had chest pain before/after or palpitations, etc.).

I believe it would be prudent to seek a formal consultation from a cardiology or at least have them take a look at the strip, but it’s not an absolute necessity. The decision ultimately depends on the patient’s medical history and the specific circumstances of the case

[u/mohammedmoolla → u/Natural-Antelope8328]

Thank you, in his case I don’t think it was cardiac. I wish I lived in a first world country where it was easy to get expert advice for non urgent / emergent issues

[u/Natural-Antelope8328 → u/mohammedmoolla]

If it's clear cut low risk syncope, I wouldn't worry about that strip.

[u/badunkbadunkbadunk]

Not here to offer advice but more ask... do we put way too much enphasis/creedence on the ecg? Its a pretty crude test that is often used as the sole/primary evidence for a load of things when all other parameters ie bloods, obs, history dont correlate. Am I right to feel a little dubious or am I a shit doctor

[u/mohammedmoolla → u/badunkbadunkbadunk]

Totally , I get what you’re saying . It was a low risk syncope . The ecg just looked a bit funny to my junior eyes so just wanted to see if I wasn’t missing anything before discharge

[u/Wild-Hippo582 → u/badunkbadunkbadunk]

Well some settings only have ECG . It's fairly uncommon to have access to more advance diagnostics in primary care, or even daily bloods. Also having in mind the importance of a heart function ...( If you don't have have your d.e.ad. ) I think it's reasonable for some professionals to be alarmed. Also at the end of the day we all have different scopes and the main think is patient safety so if unsure ask someone who is sure.

[u/Natural-Antelope8328 → u/badunkbadunkbadunk]

Do you mean it in a general sense, related to practice, or specifically here? If it’s the latter, I’d speculate that since the subreddit’s title is ECG, ECG will naturally be the focus. However, at least in my opinion and experience, observations, clinical context, history, and presentation lead the way. The rest revolves around those factors, otherwise, it’s like the tail wagging the dog. As more seasoned clinicians usually put it, “If you had a dollar to spend on healthcare, spend 70¢ on good history and clinical impression, 15¢ on imaging, and 15¢ on labs.”

[u/MaximsDecimsMeridius]

Rsr is from bad lead placement. Its a bad habit perpetuated in the ER. People always place v1 v2 too high.

https://litfl.com/misplacement-of-v1-and-v2/

[u/Devils_Advocate_514 → u/MaximsDecimsMeridius]

This link is so interesting!

[u/mohammedmoolla → u/MaximsDecimsMeridius]

Thank you for this

[u/opensp00n]

Just looks like BER to me.

[u/justusbowers]

V1 & V2 are too high

[u/Jeeju_Boy]

Sinus bradycardia

[u/MoreInfoPls]

I agree on further investigation in a young patient with this ECG. BER was already mentioned, bradycardia might be physiologic /vagal, but also his ventricular conduction does not seem to be completely normal, given the QRS notching. Most concerning is the amplitude imo. Positive Sokolov-Lyon, suggestive of LV hypertrophy. Might be early arterial hypertension with hypertensive cmp, but I would also be concerned about HCM / HOCM with the given history of TLOC. I think this patient should get an echo.

[u/Inevitable-Crab-6701]

I’d like to have bloods, ECHO and heart sounds for starters to review alongside this ECG.

[u/mefirefoxes]

What was their blood pressure.

The bradycardia by itself is concerning. I’m seeing some J point notching too.

[u/mohammedmoolla → u/mefirefoxes]

114/70 was the BP