Three days ago, a 62-year-old man was admitted with chest pain and an MI (confirmed by cardiac enzymes). The chest pain started while he was working on his farm, but he did not seek immediate help because he assumed it was heartburn and he had chores to finish. When the pain did not resolve overnight, he finally presented to the emergency department. Cardiac catheterization revealed an occluded left anterior descending (LAD) artery distal to the first diagonal branch and diffuse disease in the circumflex and right coronary arteries. An echocardiogram showed diffuse left ventricular hypokinesis and no evidence of valvular disease. His left ventricular ejection fraction was estimated to be 48%. Medical history is remarkable for hypertension and gout. Surgical history is remarkable for an appendectomy at age 7 and surgical repair of a fractured tibia from a high school football injury. Family history is positive for coronary artery disease; both parents died at young ages (father at 60, mother at 65) of MI, and his older brother had an MI at age 50 (but is currently doing well). The patient owns a 475-acre farm on which he grows corn and soybeans. He also tends to 23 cows and has a large chicken coop. There are five workers to help, but he states that he does most of the work himself. He is divorced and lives alone with five dogs, whom he refers to as his “kids.” He does not smoke, but he has one beer and one shot of bourbon with dinner each night. His only medication at the time of admission was ibuprofen. He had been prescribed lisinopril in the past but hadn’t taken it in six months because “it’s too far a drive to get it refilled.” He has no known drug allergies. Following admission, he was started on a β-blocker (metoprolol), aspirin, atorvastatin, and lisinopril. During rounds, you notice that his hypertension is well controlled. His blood pressure is 118/80 mm Hg, compared to 180/92 mm Hg on admission. He is comfortable and wants to know when he can go home. As you contemplate discharge, a technician hands you the patient’s daily ECG tracing. It shows a ventricular rate of 56 beats/min; QRS duration, 106 ms; QT/QTc interval, 400/386 ms; P axis, 36°; R axis, 120°; and T axis, 7°. What is your interpretation of this ECG?
