A 75-year-old woman presents to the emergency department, anxious and in severe distress, reporting “the worst case of shortness of breath I’ve ever had.” During the preceding 24 hours, she states, she felt “progressively ill,” with fevers and chills. However, she denies any episodes of chest pain.
The patient had rheumatic fever as a child but had no cardiac or pulmonary symptoms until August 2009, when she experienced a non–ST elevation myocardial infarction (NSTEMI) while on vacation. A workup during admission for that event showed a long, tubular 80% lesion of the left anterior descending artery, no significant circumflex or right coronary artery disease, pulmonary artery (PA) pressures of 62/21 mm Hg, a mean PA pressure of 37 mm Hg, and a left ventricular ejection fraction of 70% with severe mitral regurgitation. She was treated conservatively during that admission, as surgical intervention was deemed to involve too high a risk.
Since returning home, she has had three successive admissions for shortness of breath. All were managed by adjustment of her medications. Her medication list includes aspirin, carvedilol, valsartan, isosorbide mononitrate, furosemide, potassium chloride, and simvastatin.
Vital statistics include a height of 167 cm; weight, 62 kg; blood pressure, 156/66 mm Hg; pulse, 72 beats/min; and temperature, 39°C. Pertinent physical findings include no jugular venous distention, a grade IV/VI high-pitched holosystolic murmur, rales in all lung fields with diminished breath sounds in both bases, and cool extremities with good pulses and trace edema.
A chest x-ray reveals bilateral pleural effusions with adjacent atelectasis and patchy opacities in the right middle lobe fields. Pertinent laboratory data include normal cardiac enzyme and electrolyte levels, a serum glucose level of 201 mg/dL, a hematocrit level of 31%, and a white blood cell count of 14.21 x 103/uL.
ECG reveals the following: a ventricular rate of 72 beats/min; PR interval, 124 ms; QRS duration, 124 ms; QT/QTc interval, 444/486 ms; P axis, 269°; R axis, –44°; and T axis, 147°. What is your interpretation of this ECG?