E-page Original Images: Challenging electrocardiography

A 62-year-old female patient was admitted to our hospital after DC cardioversion because of complaints of palpitation, dizziness and presyncope and wide QRS tachycardia on her electrocardiography. Her past medical history revealed hypertension for 20 years. She was on medical treatment with metoprolol and ramipril. Her blood chemistry was in normal range. Transthoracic echocardiography revealed normal left ventricular ejection fraction, left ventricular hypertrophy, enlarged left atrium, moderate mitral regurgitation, moderate tricuspid regurgitation with a pulmonary artery pressure of 50mmHg. Electrocardiography (ECG) showed short PR interval, an early transition zone in the precordial leads, increased notched p wave duration in inferior leads. During follow-up atrial flutter episodes were detected. Wide QRS tachycardia episodes with positive concordance and capture beats were also recorded (Fig. 1).