No textbook. No carefully manufactured exam question. A sad looking middle aged person presented for medical assessment, and this ECG was recorded. Chest pain for a while now, they said. Someone passes you the strip to sign and says “this looks odd, innit?” The patient is awake. Talking. What do you see? 1. What is the diagnosis? 2. Which leads give it away? 3. Where is the culprit likely to be? 4. What are you doing next? And when? Because the ECGs we learn for exams eventually stop being exam questions. One day, there’s a real person sitting in front of you. #ecg #ecgdecoded #medicaleducation #emergencymedicine #cardiology

Middle-aged man. Severe chest pain radiating to the jaw. BP dropping. Monitor beeping. The ECG prints… and everyone thinks it’s just an inferior STEMI. But this one’s smarter. what else do YOU see on this ECG? #ecg #ecgdecoded #emergencymedicine #cardiology #medicaleducation

He’s in his mid-70s Ex-smoker. Struggling for air Cough that shakes the bed. You print the ECG - and the story unfolds before the monitor even stops scrolling Right-axis deviation. Towering P waves in leads II, III, aVF. Barely any R waves in V1–V3. Deep S waves in V5 And a heart twisted vertically like it’s gasping for room. This isn’t a left-heart problem. It’s a lung problem written in electricity. Cor pulmonale - chronic pulmonary strain. Years of COPD, hypoxia, and back-pressure sculpted into this tracing Here’s what’s happening: Every breath he’s ever fought for forced the right ventricle to bulk up and twist the heart’s axis. The result? P pulmonale. Right-axis deviation. Low voltage left leads The full electrical fingerprint of a lung-driven heart. The danger? People chase the oxygen, the infection, the wheeze - and miss the story that’s right there on paper. Because this isn’t “just COPD.” It’s the right heart on its knees. A useful teaching shortcut: Cor pulmonale = right atrium + right ventricle under pressure So on the ECG, look for P pulmonale + RAD + RVH ± RV strain/RBBB. Importantly, none of these findings alone diagnoses cor pulmonale. The ECG in cor pulmonale may even be relatively unremarkable, and the diagnosis ultimately depends on the clinical picture and cardiac/pulmonary assessment. Follow us for more ECG breakdowns #ecg #ecgdecoded #ekg #ecginterpretation #ecgeducation

Man walks into the ED. Yesterday he had chest pain today, he feels fine. Trops are normal. Junior says, “Discharge, right?” But the consultant freezes. They look at the ECG and whisper “Don’t you dare stress-test this man.” This… is Wellens’ Syndrome, the heart’s calm before the storm. Those deep, symmetrical T-wave inversions in V2 to V6, and sometimes in I and aVL? They’re not “nonspecific.” They’re the LAD artery screaming quietly before it dies. Let me show you what’s happening here: - The artery is partially occluded, pain settles as blood trickles back in. - The ECG shows massive repolarization changes - deep, symmetric T inversions. - ST segments? Flat. - QRS? Narrow. - Trops? Barely touched. - But make no mistake - this is a pre-infarction warning. Miss it, and the next pain isn’t a twinge - it’s a full LAD occlusion. You don’t do a treadmill. You don’t “review in clinic.” You admit, angiogram, revascularize. Because Wellens is not subtle. It’s polite but deadly. When you see deep, symmetrical T-wave inversions in the anterolateral leads (V1 to V6, I, aVL) after pain resolves think Wellens. If they’re biphasic (down then up)? That’s Type A. If they’re deeply inverted like this? That’s Type B the classic LAD signature. Before you call another ECG “nonspecific,” learn to spot the heart’s warning whispers. Comment “DECODE” if you want the 3-step pattern-recognition framework I use to spot killers like this before trops even rise. #ecg #ecgdecoded #cardiology #medicaleducation #emergencymedicine