70-year old patient presenting with chest pain and diaphoresis. Describe the ECG.

30-year old Thai male presenting with syncope. Describe the ECG.

What diagnosis

This is the classic picture of digoxin effect, with “sagging” ST segments and T waves taking on the appearance of “Salvador Dali’s moustache“

Digoxin effect refers to the presence on the ECG of:

Downsloping ST depression with a characteristic “reverse tick” or “Salvador Dali sagging” appearance
Flattened, inverted, or biphasic T waves
Shortened QT interval

Sagging ST depression is clearly evident in leads I, II, III, aVF and V5-6
Frequent premature ventricular complexes (PVCs) suggest the possibility of digoxin toxicity

This is the classic picture of digoxin effect, with “sagging” ST segments and T waves taking on the appearance of “Salvador Dali’s moustache“

Discrete U waves

Rollercoaster” U waves

Downsloping TP segment seen as an early ECG manifestation in ~30% of patients with pericarditis, best visualised in leads II and the lateral precordial leads

Example 2: Pericarditis

ST-segment-T-wave-ratio-pericarditis
ST segment height = 2 mm
T wave height = 4 mm
ST / T wave ratio = 0.5
The ST / T wave ratio > 0.25 is consistent with pericarditis.

Benign Early Repolarisation

ST-segment-T-wave-ratio-Benign Early Repolarisation
ST segment height = 1 mm
T wave height = 6 mm
ST / T wave ratio = 0.16
The ST / T wave ratio < 0.25 is consistent with BER

RBBB + STEMI

RBBB

78 yr old male presents with a 2 day history of lethargy and dizziness. He has a history of ischaemic heart disease, type 2 diabetes, hypertension, and chronic renal failure. His medications include calcium-channel blocker, beta-blocker, and ACE-inhibitor.

He is conscious with systolic BP of 70.

97 year old gentleman found unconscious at home. Brought into emergency by ambulance at 10am having last been seen at 8pm the evening before.