Former Farmer Is Short of Breath
ANSWER
The correct interpretation of this ECG includes normal sinus rhythm with left atrial enlargement and a left bundle branch block (LBBB). Normal sinus rhythm is evidenced by a P wave associated with each QRS complex with a consistent PR interval.
Left atrial enlargement is evidenced by a P-wave duration ≥ 120 ms in lead II, a notched P wave in the limb leads with a peak duration ≥ 4 ms, and a terminal P-wave negativity in lead V1 with a duration ≥ 4 ms and a depth ≥ 1 mm.
An LBBB is illustrated by the QRS duration ≥ 120 ms, a dominant S wave in lead V1, broad monophasic R waves in the lateral leads (including I, aVL, V5, and V6), and R-wave peak times of > 60 ms in leads V5 and V6.
Further work-up revealed elevated left end-diastolic filling pressures, volume overload, and pulmonary edema consistent with diastolic heart failure. Given the unclear etiology of the LBBB, cardiac catheterization was performed. It revealed no significant coronary artery disease.