ECG sharing 高醫心臟內科 蔡維中 Assistant professor Kaohsiung Medical University
2018@ Kaohsiung
Part I. ECG practices
Case 1 • 54 y/o female • CC：Dizziness for several years. • PH：DM(-), HTN(-),
150 Hz
25.0mm/s
10.0 mm/mV
What`s the diagnosis? 1. 2. 3. 4.
Q wave MI CRBBB Normal sinus rhythm Low voltage (precordial leads)
Normal sinus rhythm
Case 2 • 73 y/o female • CC：Intermittent dizziness for 1 month. • PH：DM(+), HTN(+), Transient ischemic attack(+), CKD(+)
What`s the diagnosis? 1. 2. 3. 4.
First degree AVB + CRBBB Mobitz type I AVB Af + CRBBB Complete AVB
Complete AVB
Case 3 • 60 y/o female • CC：Palpitation intermittently for several months. • PH：DM(-), HTN(-), Heart disease(-), received procedure in hospital one year ago.
What`s the diagnosis? 1. 2. 3. 4.
Sinus tachycardia with bundle branch block Ventricular tachycardia Pacemaker rhythm WPW syndrome
Pacemaker rhythm
AAI Pacing
VVI Pacing
Atrial Sensing and Ventricular Pacing
Case 4 • 60 y/o Male • CC：Chest discomfort, palpitation and dyspnea for 2 months. • PH：DM(-), HTN(-), Heart disease(-),
What`s the diagnosis? 1. 2. 3. 4.
Sinus tachycardia Atrial tachycardia PSVT Atrial flutter
Atrial flutter
Atrial tachycardia
Atrial flutter Orthodromic AVRT
AV Node
AV nodal reentrant tachycardia
NEJM. 2006; 354:1039-51.
Arrhythmia and valsalva`s maneuvers
NEJM. 2006; 354:1039-51.
Braunwald Heart 10ed
Case 5 • 58 y/o Male • CC：Pale face, cold sweating and chest tightness 3 hours ago. • PH：DM(-), HTN(+), Dyslipidemia(+),
What`s the diagnosis? 1. 2. 3. 4.
Sinus bradycardia Inferior wall MI Non-specific ST-T change Junctional rhythm
Inferior wall MI
ECG NOTES. Interpretation and Management Guide. Shirley A. Jones
ECG NOTES. Interpretation and Management Guide. Shirley A. Jones
Case 6 • 65 y/o Male • CC：Sudden onset of conscious change for one minute 2 days ago. • PH：DM(+), HTN(+), CAD(+) s/p CABG
What`s the diagnosis? 1. 2. 3. 4.
Sick sinus syndrome (SSS) AFL with bundle branch block AFL with complete AV block AT with variable block
AFL with complete AV block
Case 7 • 56 y/o Male • CC：Shortness of breath during exercise in recent 6 months.
• PH：DM(-), HTN(+), Dyslipidemia(-), • FHx：Fabry disease
Which diagnosis is wrong? 1. 2. 3. 4.
LVH with strain Coronary artery disease with myoischemia Hypertrophic cardiomyopathy Sinus bradycardia
Coronary artery disease with myoischemia
T wave Inverted ________________________________________________________________
Bundle Branch Block Pericarditis Pulmonary Embolism Left Ventricular Hypertrophy Digitalis Effect CNS injury Ventricular Paced Rhythm Intra-abdominal Disorders Metabolic Toxic Toxic Pre-excitation Syndrome Juvenile T wave Pattern Emerg Med Clin N Am 24 (2006) 91–111.
Braunwald Heart 10ed
Case 8 • 65 y/o Male • CC：Chest tightness since 2015/6/15 23:00 (1 hour ago) • PH：DM(+), HTN(+),
2015/6/16 0 AM
2015/6/16 9 AM
2011/10/06
What`s the diagnosis? 1. 2. 3. 4.
Tent T wave - hyperkalemia T wave inversion – Takotsubo cardiomyopathy Hyperacute T wave – Anterior wall STEMI Non-specific ST-T change
Hyperacute T wave – Anterior wall STEMI
Emerg Med Clin N Am 24 (2006) 91–111.
Emerg Med Clin N Am 24 (2006) 91–111.
Tall T wave Tented T wave
Hyperacute T wave
http://www.medscape.com/viewarticle/576765_2
Biphasic T wave - Wellens syndrome
Case 9 • 79 y/o Female • CC：Shortness of breath, chest tightness and dizziness for 2 days. • PH：DM(-), HTN(+), breast cancer(+),
What`s the diagnosis? 1. 2. 3. 4.
Q wave MI Acute pulmonary embolism NSTEMI Left side pneumothorax
Acute pulmonary embolism
Why do you make this diagnosis? 1. 2. 3. 4.
All
Sinus tachycardia S1Q3T3 ICRBBB with TWI in V1 – RV strain pattern All
ECG patterns of pulmonary embolism • sinus tachycardia (most common, 8-69%), • right axis deviation, right bundle branch block • S1Q3T3 (12-50%) • RV strain (inverted T waves in lead V1-V4, ST elevation in aVR)
Case 10 • 35 y/o Male • CC：Chest pain and fever for 3 days. • PH：DM(-), HTN(-), Dyslipidemia(-),
What`s the diagnosis? 1. 2. 3. 4.
Acute pericarditis Acute pulmonary embolism Acute myocarditis STEMI
Acute pericarditis
ECG patterns of acute pericarditis Stage 1: Diffuse ST elevation (except ST depression in aVR, V1) . Diffuse PR depression (except PR elevation in aVR).
Stage 2: The ST and PR become normal (isoelectric); Stage 3: ST normalized diffuse T wave inversion
Stage 4: The T waves normalize. ECG INTERPRETATION: FROM PATHOPHYSIOLOGY TO CLINICAL APPLICATION. Fred Kusumoto, MD
Case 11 • 51 y/o Female • CC：palpitation intermittently for few years. • PH：DM(-), HTN(-), Dyslipidemia(-),
ECG during palpitation
What`s the diagnosis? 1. 2. 3. 4.
Sinus tachycardia Myoischemia, r/o NSTEMI Ventricular tachycardia (VT) Paroxysmal supraventricular tachycardia (PSVT)
Paroxysmal supraventricular tachycardia (PSVT)
Baseline ECG
ECG during palpitation
What`s the diagnosis? 1. 2. 3. 4.
Atrioventricular nodal reentry tachycardia (AVNRT) Atrioventricular reentrant tachycardia (AVRT) Atrial flutter (AFL) Atrial tachycardia (AT)
Atrioventricular nodal reentry tachycardia (AVNRT)
AV nodal reentry SVT (junctional tachycardia)
Orthodromic SVT AV nodal reentry SVT (atrial tachycardia)
Atrial tachycardia Atypical AV nodal reentry Orthodromic SVT (slowly conducting AP)
Braunwald Heart 10ed
Sinus tachy
AT
AVNRT
AVRT
Harrison'sâ„¢ PRINCIPLES OF INTERNAL MEDICINE, 18th ed
I
aVR
V1
V4
II
aVL
V2
V5
III
aVF
V3
V6
BASELINE PSVT
Braunwald Heart 10ed
Part II. Dangerous ECG
Criteria for VT
Simple rules • RV outflow tract VTs terminated by Vagal maneuvers • LV free wall VTs RBBB contour • RV or septum VTs LBBB contour • Septal VTs narrower QRS complexes
• Apical VTs negative precordial concordance
Simple rules • Basal VTs positive concordance • Posterior (inferior) LV/RV VTs negative QRS in II, III, aVF • Outflow tract VTs positive QRS in II, III, and aVF
• Epicardial VTs delayed intrinsicoid (initial) deflection that slurs the early portion of the QRS complex (>55% of QRS duration.)
RVOT VT (LBBB + inferior axis)
Left septal VT (RBBB + superior axis)
Hyperkalemia ïƒ Sine wave
Accelerated Idioventricular Rhythm (AIVR)
Torsades de Pointes
Short Long Short
QT prolong
Artifacts 45 y/o male, Severe PN and respiratory failure s/p intubation ďƒ MICU
ILVT 35 y/o female, No underlying disease.
Sudden onset palpitation ďƒ ER
AF + WPW 70 y/o male,
Hx of DM, HTN, HF. Sudden onset palpitation, dizziness ïƒ ER
Hyperkalemia – tented T 60 y/o female,
Hx: ESRD on HD. Gradually onset of weakness, palpitation ER
References • Rapid ECG Interpretation Third Edition • Dr. Kun-Tai Lee and Chee-Siong, Lee`s teaching files • The ECG in Emergency Decision Making 2nd edition • Braunwald's Heart Disease 10th edition 2015
• Harrison's Principles of Internal Medicine 19th Edition
Thank you for your attention!
蔡維中 azygo@msn.com