ECG Workshop Nezar Amir Case one A 61-year-old man with a history - - PowerPoint PPT Presentation
ECG Workshop Nezar Amir Case one A 61-year-old man with a history of hypertension and congestive heart failure presents to the emergency department with shortness of breath after eating breakfast. All of the following statements about his ECG
Case one
A 61-year-old man with a history of hypertension and congestive heart failure presents to the emergency department with shortness of breath after eating breakfast. All of the following statements about his ECG are correct EXCEPT: a) The QRS axis is normal b) The rhythm is sinus tachycardia c) The PR interval is within normal limits d) There is a complete left bundle branch block e) The voltage in the chest leads meets criteria for left ventricular hypertrophy
a) The QRS axis is normal b) The rhythm is sinus tachycardia c) The PR interval is within normal limits d) There is a complete left bundle branch block e) The voltage in the chest leads meets criteria for left ventricular hypertrophy
The criteria for complete LBBB include:
1.Prominent voltage in the chest leads and selected limb lead 2.Widened QRS 3.T wave inversions in leads with tall R waves 4. Left axis deviation
with caution. Commonly used voltage criteria include
1. SV1 + RV5
V6 > 35 mm (3.5 mV) 2. RaVL > 11 mm (1.1 mV) 3. For men: SV3 + RaVL > 28 mm (2.8 mV) 4. For women: SV3 + RaVL > 20 mm (2.0 mV)
a) The PR interval is prolonged b) The QRS axis is normal c) There is normal R wave progression d) There is a complete right bundle branch block e) There is evidence of right ventricular hypertrophy
Criteria for RVH
RV hypertrophy occurs over time in response to pressure or volume
1. Primary pulmonary hypertension 2. Chronic obstructive pulmonary disease (COPD) 3. Pulmonic stenosis 4. Atrial septal defect (ASD). This patient was diagnosed with PAH
Case 3; The above ECG is from a 64 year old Caucasian male referred by the primary care physician to the cardiac outpatient clinic because of a very abnormal ECG. The patient is asymptomatic, without any sort of chest pain, dyspnea, palpitations, or previous syncope or dizzy spells. The BP is 130/80 mmHg and there are not murmurs on auscultation.
ECGs similar to this one can be seen in 1. Athletes of African or Afro-American origin without the phenotype of hypertrophic cardiomyopathy: our patient is Caucasian and is not an athlete, but a 64 year old male in whom his primary care physician
2. Severe hypertensive heart disease: the blood pressure in this patient was normal 3. Valvular aortic stenosis: there were no heart murmurs on auscultation 4. Hypertrophic cardiomyopathy: the absence of murmurs should prompt us to consider a non-obstructive hypertrophic cardiomyopathy
Case 4; The above ECG is from a 53 year old male with a history of high blood pressure for the last couple of years. He is overweight and has mild hyperglycemia. He is referred by the primary care physician to the cardiac outpatient clinic because of a history of episodes of palpitations during the last 3 months, unrelated to exercise, of a very short duration, two or 3 times per month. On auscultation there is a 2/6 systolic murmur along the left sternal border and a wide splitting of the second heart sound.
a) Normal variant early repolarization pattern b) Physiologic sinus arrhythmia c) Normal AV conduction d) Left axis deviation e) Transition zone in lead V3
d) Left axis deviation This ECG shows a normal variant that is commonly referred to as early repolarization pattern." There are ST elevations in leads V2-V6 and in some of the limb leads. Slight notching of the terminal QRS (V4) is often seen in conjunction with this pattern. The ST segment retains its normal upward concavity. The QRS axis here is normal (about +30 degrees). The QRS transition zone (R=S) is in lead V3, a normal finding. AV conduction is normal, indicated by the normal PR interval (about 0.14 sec.) The slight variation in heart rate is due to physiologic (respiratory) sinus arrhythmia.
a) Left atrial abnormality b) Anterior ischemia c) Normal variant T wave inversions V1-V2 d) Hypokalemia e) Left ventricular hypertrophy
New ST elevation at the J-point in two contiguous leads with the cut-off points: ≥ 0.2 mV in men or ≥ 0.15 mV in women in leads V2-V3 and/or ≥ 0.1 mV in other leads.
New horizontal or down-sloping ST depression > 0.05 mV in two contiguous leads: and/ or T inversion ≥ 0.1 mV in two contiguous leads with prominent R-wave or R/S ratio ≥ 1.
elevation in AVR
tachycardia)
> I or in AVL), or RCX ( in 20%). (often bradycardic due to sinus node
V4 right helps diagnose right ventricular involvement (in RCA occlusion)
more about this topic on ECGpedia...
Notice the rather typical relative absence of ST deviation.
a) Complete right bundle branch block b) Complete left bundle branch block c) Wolff-Parkinson-White pre-excitation (right sided bypass tract) d) Left anterior fascicular block e) Left posterior fascicular block
Note the ST depression and T-wave inversion in leads V2-V6.
Question:
What area of the heart is infarcting?
Anterolateral
Right BBB
a right vs. left bundle branch block).