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?
