A 19 year old with panic attacks. On the previous ECG, the diagnosis was missed, as it frequently is!

This young woman presented with recurrent anxiety attacks with chest pain and dyspnea.  She was otherwise healthy except for history of cholecystitis and cholecystectomy one year prior.

I saw her in triage and ordered an EKG:

What do you think?  How did I interpret this?

There is a short PR interval.  The eye is taken immediately to the ST depression and T-wave inversion in multiple leads.  But as I pointed out in this recent post (I thought the ECG diagnosis was obvious. But many missed it. So I'm showing it.) when there are ST-T abnormalities, one must look at the entire PQRST and look for reasons that the ST-T is abnormal SECONDARY to PQRS abnormalities.  

Repolarization abnormalities may be entirely due to depolarization abnormalities.

Again in this case, in addition to the ST depression and T-wave inversion in multiple leads, there is a short PR interval, and an unusual delta wave in multiple leads.  There is a large R-wave in V1, with an RSr'. This is another case of WPW.  

WPW entirely explains the patient's symptoms, as WPW is strongly associated with (because it causes) episodes of SVT (or AVRT).  

More technical: Where is the insertion of the accessory pathway?  The RSr' in V1 is similar to RBBB, and indicates that the accessory pathway is on the left side, with the late forces to the right.  R-waves are positive throughout the precordium, indicating a probable posterior insertion of the accessory pathway.  There is also an inferior axis, which indicates that the pathway inserts into the left ventricle at a superior location.  So one would expect the insertion to be in the posterior superior left ventricle.

There was a previous ECG in the system, recorded at the time of her cholecystitis:

The interpretation by BOTH the computer and the overreading physician was:

SINUS RHYTHM WITH SHORT PR INTERVAL

POSSIBLE RIGHT VENTRICULAR CONDUCTION DELAY [RSR (QR) IN V1/V2]

But this one is also diagnostic of WPW,  so the diagnosis was missed by both the computer and the overreading physician.

Electrophysiology was consulted and she received a Zio Patch with EP Followup.

SVT is a common cause of panic attacks and is frequently misdiagnosed as panic attack.

• Lessmeier et al. performed a retrospective survey in 107 patients with reentrant paroxysmal SVT and found that 67% had symptoms fulfilling the DSM-IV criteria for panic disorder.  Only 48 (45%) patients were correctly diagnosed upon initial evaluation; 55% were undiagnosed for a mean of 3.3 y following initial presentation, including 13 patients with apparent pre-excitation on resting ECG. Physicians initially attributed symptoms to “panic, anxiety or stress” in half of these patients, with women more likely than men to have their symptoms attributed to psychiatric causes (65% vs. 32%; P <.04).

Lessmeier TJ, Gamperling D, Johnson-Liddon V, et al. Unrecognized paroxysmal supraventricular tachycardia. Potential for misdiagnosis as panic disorder. Arch Intern Med. 1997;157(5):537-543.