SHA24/013001

Dr. Haitham Alanazi FRCPC, ABIM

Electrophysiologist Cardiologist King AbdulAziz (National Guard) Cardiac Center Riyadh

SHA24-GHA10 ECG workshop BOOK Prepared by: 1. Waleed Almanee - SFH 2. Majed Alfayaadh - KFSH 3. Bander Alghamdi - KFSH 4. Faisal Alsmaidi - KFMC 5. Joe Akar - Yale university 6. Haitham Alanazi - KACC 7. Azam Shafgat - KFSH 8. Abdulmohsen Almusa'ad - KACC

•Case 1 • 17 year old male • High school graduate • Applying for Air Force Academy • Completely asymptomatic

•What is the diagnosis?

A- Hypertrophic Cardiomyopathy B- Wolf-Parkinson-White Syndrome C- Brugada Syndrome D- Long QT syndrome E- Aortic Stenosis

•Where is the AP located?

A- Right Anterior Septal B- Right Posterior C- Right Anterior D- Left Anterior E- Left Posterior

•How do you manage him?

A- No further testing B- Holter monitoring C- Stress testing D- Start Diltiazem E- EP study

• • • •

Case 2 42 year old male presented with syncope Two children aged 3 and 5 years old No family history of arrhythmias or SCD

Echo reveals septum of 3.1 cm

HOCM – Hypertrophic cardiomyopathy (HCM) is a disease of sarcomeric proteins.

– Genetic inheritance is autosomal dominant – Anatomical sub-types: ASH, concentric and apical – Sudden Death is 1% per year.

Athletes with SCD and HOCM

Facts About Hypertrophic Cardiomyopathy : - Hypertrophic cardiomyopathy is the leading cause of death in young athletes.

- This is the most common inherited cardiovascular disease.

- Over 200 mutations identified.

- First degree relatives should be screened.

- If echo is normal in an 18 years old first degree relative , then a follow up echo should be done every 5 years through adulthood.

Case 3 • 22 year old girl • ECG was done during routine check up • No family history of SCD

What is the diagnosis?

A) Ectopic atrial rhythm B) WPW Syndrome C) Brugada Syndrome D) Long QT syndrome E) Aortic Stenosis

What is the next step in her management?

A) No further testing B) Start betablocker C) Left Stellate Gangilionectomy D) ICD implantation

• • • •

Case 4 A 55 year old man with syncope Previous history of MI Noted to have frequent PVCs, occasional NSVT (4 beats maximum) on Holter monitor.

• Echo = EF=39% • No evidence of ischemia on EST • Which is the appropriate approach : A) Start amiodarone B) Start flecanide instead of amiodarone to avoid undesirable side effects of amiodarone C) Implant an ICD as per SCD-HFT trial recommendation.

D) Refer him for electrophysiological study (EPS)

Fast VT induced during EPS

Case 5 : - 13 years old boy , was well till 6 months back.

- Had episodes of dizziness while climbing stairs.

- History of syncope while playing football.

ECG and rhythm strips at baseline and during exercise testing

Which of the following is appropriate : A) Start amiodarone B) Admit urgently for EP study C) Diagnosis is long QT syndrome with torsade de point VT D) Start oral B- blockers , with close follow up E) ICD implantation

Case 6 A 45 years old male, he is asymptomatic and no family hx of SCD

What will you do?

A) B) C) D) E)

Leave him alone.

ICD if drug challenge test positive ICD if both drug challenge test and EPS were positive.

ICD if genetic test positive.

Start Quinidine if EPS positive.

Case 7 50 year old gentleman Admitted with symptoms of heart failure - Permanent pacemaker implanted for complete heart block 2 years ago - Normal echo prior to that - Normal coronary angiogram - Functional Class II on medical therapy - Echo now showed moderate to severe left ventricular dysfunction

• What is the most likely cause for this deterioration in left ventricular function A. B. C. D. E.

Familial Cardiomyopathy Non ischemic dilated cardiomyopathy Tachycardia induced cardiomyopathy Pacemaker induced cardiomyopathy Hypertrophic cardiomyopathy

What would be the best way to treat this condition in this patient?

A. B. C. D. E.

Change pacemaker mode from DDD to AAIR Change pacemaker mode from DDD to VVIR Upgrade to CRT (Biventricular) pacemaker Upgrade to Dual Chamber ICD Upgrade to CRT- D (Biventricular ICD)

Case 8 A 45 year lady with palpitation and documented WCT Her brother died suddenly when he was 50 year old

During tachycardia

The most likely diagnosis from ECG is: a) b) c) d) e)

Brugada syndrome Arrhythmogenic right ventricular cardiomyopathy/Dysplasia (ARVC/D) Right ventricular outflow tract VT Dilated cardiomyopathy Long QT syndrome

What is the best diagnostic test? a) b) c) d)

Echocardiogram Cardiac CT Genetic test Cardiac MRI

Fatty infiltration of the RV

Case 9 A 34 year old female, a survivor of VF cardiac arrest with normal cardiac work up

The ECG shows: a) b) c) d) e)

Long QT interval WPW Short QT Early repolarization Normal ECG

What is the next step her management: a) b) c) d) e)

Start Amiodarone Start beta blockers EPS ICD implantation Do nothing

6 months after ICD: Had a shock while biking

A shock while biking

Case 10 A shock while watching TV

65 M, DCM, EF 25% - Primary prevention ICD 2009, No therapy recorded - Had a shock while watching TV, no proceeding symptoms. No syncope.

-

In the ER: ECG: similar to baseline P/E, and blood work: within normal

Chest X-ray

A shock while watching TV

While waiting in ER: had another shock with no documented arrhythmia in the monitor

A shock while watching TV

Case 11: 35 yo male with chest pain

The best approach is: A) Treat as a STEMI and call the cath lab B) Initiate antibiotic C) Give thrombolytics D) Start a high dose asprin and follow clinically E) CTA lung to role out PE

Case 12 • A 23-year-old male with no known medical history suddenly collapsed while playing soccer. His friends immediately started CPR. The paramedics arrived within 5 minutes and found him in VF. He was defibrillated successfully with one shock. He was transported to the hospital for subsequent care. • The following ECG was obtained upon arrival to the hospital:

What is the most likely diagnosis?

A) Short QT syndrome B) Long QT syndrome C) Brugada syndrome D) Catecholaminergic polymorphic VT E) Acute MI

The patient made a complete neurologic recovery.

An echocardiogram is within normal limits. What is the next appropriate step in management?

A)Start a beta blocker and restrict him from participation in competitive sports B)EP testing with administration of a class 1 antiarrhythmic (flecainide and procainamide) to determine risk of sudden death C) Exercise testing to assess if his QT shortens appropriately D) Implant an ICD E) Implant a dual-chamber pacemaker

Case 13

What is the next step in his evaluation?

A) Exercise TMT B) He can not play any competitive sport C) No further evaluation is required D) Empiric treatment with a beta blocker E) None of the above

BP 120/70

Which of the following medications would be an appropriate initial therapy?

A) Lidocaine B) Adenosine C) Metoprolol D) Procainamide E) Diltiazem

Case 14: 27 yr old female, has hx of syncope, treated with beta blockers, she discontinued the treatment during pregnancy, but resume it recently. No symptoms after the treatment.

Her sister died at age 32 yr. The most likely diagnosis?

A) WPW B) HOCM

C) familial dilated cardiomyopathy D) LQTS

All of the following medications are known to prolong the QT interval and potentially cause torsades de pointes except: A) Amiodarone B) Erythromycin C) Haloperidol D) Sotalol E) None of the above

Case 15

• A 32-year-old male is referred to you by his primary care provider after an episode of syncope.

• Family history is notable for a father who died suddenly while running at the age of 45.

• Echocardiogram shows mild-to-moderate RV enlargement with a mild reduction in systolic function.

The history, examination, and tests are most suggestive of what disease process?

A) Arrhythmogenic RV dysplasia B) RVOT tachycardia C) HCM D) Long QT syndrome E) Vasovagal syncope

Case 16: 55 yo male with 4 hrs of chest pain

Seconds after the first ECG before PCI

Had PCI to the 100% occluded LAD and was started on appropriate medical therapy

What would you do next: A)Implant a secondary prevention ICD B)ICD immediately if EF less than 30% C)ICD only if his EF less than 30% after 40 days D) Start Amiodarone

The causes of SCD with Normal EF: • • • • • •

Hypertrophic Cardiomyopathy Long QT syndrome ARVC Pre excited Afib (WPW) Brugada syndrome CPVT

VT or SVT

Return

What is the rhythm?

What is the rhythm?

What is the rhythm?

Atrial flutter with LBBB

What is the rhythm?

Monomorphic VT

Case 17: What is the diagnosis in this patient with SOB and hypotension?

What would you find O/E? A) Bilateral lung crackles B) Loud S1 C) Elevated JVP with loss of Y descend D) Para sternal heave E) Radio femoral pulse delay

Case 18: 80 yr old lady with hip fracture What is the diagnosis?

PE ECG: sinus tachycardia S1 Q3 T3 pattern incomplete right bundle branch block right precordial T wave inversions

Case 19: 46 y old lady with CHF What is the diagnosis?

A. B. C. D.

Acute myocardial infarction Atrial fibrillation with IVCD Ventricular tachycardia Hyperkalemia

Thank You