EKG of the Week 2017 4-16

This EKG comes courtesy of Dr. Altberg.

A 19 year old male presents to the ED intoxicated. He also complains of palpitations. His EtOH level is 261. (This is equivalent to a blood alcohol content of 0.26).

His vital signs are: Pulse 140, Respirations 18, BP 120/80.

His EKG is below.

1.       What does the EKG demonstrate?

2.       How would you manage this patient?


The EKG demonstrates atrial fibrillation. In the setting of acute alcohol intoxication, this is known as Holiday Heart Syndrome.

The heart rate is normal. No specific interventions are necessary. The patient should be observed on telemetry until the a-fib resolves.


Patients who “binge drink” are at risk for supraventricular arrhythmias, with atrial fibrillation being the most common. It can also cause atrial flutter, atrial tachycardia, and PVC’s. These patients are typically healthy with no past history of cardiac disease. When they stop drinking, the symptoms go away. This is known as Holiday Heart Syndrome. The arrhythmias can occur at the time of drinking or up to 36 hours later.

Patients with Holiday Heart Syndrome typically present with palpitations. They may also have chest pain and syncope. There are several mechanisms that have been proposed to explain why Holiday Heart occurs.

Initial treatment of patients with Holiday Heart is the same as other patients with atrial fibrillation. If they are tachycardic, their rate should be controlled with AV nodal blockers. However, they are typically at low risk for clots and usually do not require anticoagulation. Rhythm control is usually unnecessary as the arrhythmia usually resolves spontaneously within 24 hours. They should be admitted to a monitored setting.


(Tonelo, et al. Holiday Heart Syndrome Revisited after 34 Years. Arq Bras Cardiol. 2013 Aug; 101(2): 183–189.)

(Voskoboinik, Alcohol and Atrial Fibrillation : A Sobering Review. Journal of the American College of Cardiology. Volume 68, Issue 23, 13 December 2016, Pages 2567–2576)


EKG of the Week 9-4

An 83 y/o male with a history of “heart problems” presents to the ED after a fall. His EKG is below.

1.       What is the rhythm?

2.       What other abnormality does this EKG demonstrate?



The rhythm is atrial fibrillation.

The other abnormality is Q waves in leads II, III and aVF consistent with an old inferior wall MI.

The EKG demonstrates an irregular rhythm with absent P waves and an undulating baseline. This is consistent with atrial fibrillation.

The EKG also demonstrates Q waves in leads II, III and AVF. Q waves signify an old (or “completed”) MI.

Q waves can sometimes be normal.  How can we differentiate between normal Q waves and pathological Q waves which suggest an old MI?

For Q waves to be considered pathological, they should be at least one box wide. In addition, the height of the Q wave should be at least 25% of the height of the entire QRS complex. On this EKG, the Q wave in lead II is 3 mm and the entire QRS complex is 7 mm. In lead II, the Q wave is 9 mm to a QRS complex of 12 mm. In lead aVF, the Q wave is 6 mm to a QRS height of 9 mm.

Q waves suggest an old MI. However, there is no way to tell when that MI occurred. The only way to know is to compare this EKG to a previous EKG and to correlate it with the timing of the patient’s symptoms. If a previous EKG from four months ago was normal and today’s EKG shows Q waves, that suggests the patient had an MI at some point in the last four months.