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Challenges in Clinical Electrocardiography
July 2017

An Uncommon Electrocardiogram Demonstrating a Common Cardiac Problem

Author Affiliations
  • 1Cardiology Division, San Antonio Military Medical Center, San Antonio, Texas
JAMA Intern Med. 2017;177(7):1030-1031. doi:10.1001/jamainternmed.2017.1428

An obese woman in her 60s with a medical history of poorly controlled diabetes presented to the emergency department with 24 hours of stuttering chest pain at rest and with exertion. She had been to an emergency department at a different hospital the night prior presenting for the same symptoms; however, she left that hospital against medical advice. There was no history of syncope or of palpitations. On physical examination, her vital signs showed a normal heart rate with elevated blood pressure of 152/89 mm Hg. Physical examination revealed a paradoxical split S2 heard best at the left sternal border with a soft 1/6 systolic murmur best heard at the sternal border as well. The heart sounds were distant on examination. There were rales at the lung bases bilaterally, and there was mild pitting edema at the distal lower extremities bilaterally. An echocardiogram performed the year prior had shown a normal ejection fraction with mild to moderate mitral regurgitation. The presenting electrocardiogram (ECG) is shown in the Figure. What findings does this ECG demonstrate?

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