A business professional, age 39, presents with shortness of breath that abruptly began two hours ago. He states he has been under a significant amount of stress at work during the past six months. He is approaching a deadline on a very important contract, which he says will “make or break” his career. As a result, he has been working long hours and often consumes eight to 10 cups of coffee as well as three to five energy drinks per day. After getting only three hours of sleep last night, he had two cups of coffee with a “two–energy-drink chaser.” About one hour after his last energy drink, he felt several palpitations and abruptly became short of breath. There is no history of pulmonary or cardiac illness. The patient’s medical history is unremarkable, with the exception of childhood cases of chickenpox and mumps. He has never had a surgical procedure. He takes ibuprofen on occasion after playing sports and has no known drug allergies. During college, he smoked one pack of cigarettes per day, ceasing at graduation. In response to work-related stress, he has started smoking again and is up to half a pack per day. His alcohol consumption consists of two cocktails in the evening and a 12-pack of beer on the weekends. He denies illicit drug use. The review of systems is remarkable for heartburn, bloating, and frequent indigestion. He denies nausea, vomiting, diarrhea, or constipation. The physical examination reveals a well-developed, anxious male in mild distress. His weight is 174 lb and his height is 74 in. Vital signs include a blood pressure of 90/58 mm Hg; pulse, 88 beats/min; respiratory rate, 18 breaths/min; and temperature, 98°F. His O2 saturation is 99% on room air. The HEENT exam is normal. There is no thyromegaly. The mucous membranes are pink and moist. The chest is clear to auscultation in all lung fields with excellent diaphragmatic excursion. The pulse is regular. There are no murmurs, rubs, clicks, or extra heart sounds. The abdomen is soft and nontender. The liver and spleen are not palpable. The pulses are equal and strong bilaterally. The neurologic exam is unremarkable. A chest x-ray, blood chemistry, complete blood count, and electrocardiogram are ordered. You are handed an ECG tracing that reveals the following: a ventricular rate of 84 beats/min; PR interval, 208 ms; QRS duration, 102 ms; QT/QTc interval, 358/423 ms; R axis, 20°; and T axis, 29°. What is your interpretation of this ECG?
