This 73 year old man on hemodialysis for chronic renal failure presented with prolonged chest pain and serum troponin elevation. Coronary angiography demonstrated complex lesions of the left anterior descending and circumflex arteries unsuitable for angioplasty. Bypass surgery was carried out.

• Sinus bradycardia, 49/min, with sinus arrhythmia
• Right bundle branch block, left anterior fascicular block (bifascicular block)

NOTE: The patient had regular hemodialysis throughout his hospital stay, under close supervision by the nephrology staff. His serum K was within satisfactory levels.

The patient was stable in the cardiac surgical ICU. The ECG, however, had changed

• Junctional bradycardia
• Low voltage QRS voltage in lead I (the QRS “has collapsed”)  – suspect lead placement error (arm and leg electrodes reversed) – see next slide – in this case the remainder of limb leads are uninterpretable
• ST elevation in V2-V5, consider anterior injury pattern