9/2/2015

1

Bryan Heart

2015 Bryan Heart Fall Cardiology Conference

Andrew Merliss, MD, FACC, CDRS, FHRS

Director of Cardiac Arrhythmia Service

Bryan Heart

Unknown ECGs for the Clinician

Disclaimer

Advisory Board for Medtronic Co

Clinical Research Projects Medtronic and St. Jude Co

9/2/2015

2

Case presentation:26 year old male gun salesman was driving west on route 80 near York when he woke up in a field

No recollection of events

No prior history of syncope or epilepsy

No family history of syncope (no hx of QT , HCM)

On no medications, has a normal PE and ECG

Hobby of posting dash cam recordings on the internet of bad drivers

…and had a dash cam in his car.

This patient:A. 1. Probably has epilepsy and

had a seizure

B. 2. Will probably need a pacemaker or a defibrillator

even though he is only 26.

C. 3. Has had several million hits when he posted this on YouTube.

1. Pro

bably

has

epilepsy

a..

2. W

ill p

robab

ly n

eed a p

...

3. Has

had seve

ral m

illio

n hi..

0% 0%0%

9/2/2015

3

Neurocardiogenic syncope

Mechanism – venous pooling � VR and vigorous contraction of “empty LV.” This stimulates ventricular mechanoreceptors and afferent (C-fiber activity sympathetic inhibition and parasympathetic stimulation via NTS)

– Vasodilation (Vasodepressor type)

– Bradycardia, Heart Block (Cardioinhibitory)

– Mixed

– Hypotension, Syncope

Tilt Table Test for Syncope

Abnormal responses seen during positive tilt test:

• Hypotension (Vasodepressor)

• Cardioinhibitory (Brady, Heart block, asystole—can be dramatic)

• Mixed

9/2/2015

4

Tilt Table

Response

in Patient

with

Neurally-

Mediated

Syncope

Sra JS. Ann Intern Med. 1991;114:1013-1019.

9/2/2015

5

Treatment should include:

A. Reassurance that recurrence is unlikely

B. Beta blockers

C. Beta blockers, midodrine, support hose, increased salt and volume intake

Reassura

nce th

at re

currence

...

Beta b

lock

ers

Beta b

lock

ers, m

idodrin

e, ...

0% 0%0%

The following ECG was taken on a

previously healthy 24 year old medical

student with a normal Physical Exam

9/2/2015

6

Which of the following is trueA. 1. He is unlikely to live

into his sixties

B. 2. He may have had a recent unrecognized PE

C. 3. He has a high risk of needing a future pacemaker

D. 4. He could never be accepted into the Air Force or Marine Corp with this ECG

1. He is

unlik

ely to

live

into

h..

2. He m

ay hav

e had a

rece

nt...

3. He h

as a h

igh ri

sk o

f need...

4. He c

ould n

ever b

e acce

pte...

0% 0%0%0%

If he had had a Pulmonary Embolus his rhythm would most likely be:

A. 1. Normal sinus

B. 2. Atrial fibrillation

C. 3. Atrial flutter

D. 4. Sinus tachycardia

E. 5. Ventricular

tachycardia 1. Norm

al sin

us

2. Atr

ial f

ibrilla

tion

3. Atr

ial f

lutt

er

4. Sin

us tach

ycard

ia

5. Ven

tric

ular t

achyca

rdia

0% 0% 0%0%0%

9/2/2015

7

Right Bundle Branch Block

A. 1. 1.8 per 1000 healthy Air Force Personnel between age 16 and 55

B. 2. Higher incidence at altitude

C. 3. Associated with acute MI, ASD, Ebsteins Anomaly, Chagas Dz, CMP

1. 1.8

per

1000

healthy A

ir F

or..

2. Hig

her inci

dence a

t altitude

3. Ass

ociate

d with a

cute

MI,.

..

0% 0%0%

The insect in the preceding slide is associated with the most common world wide cause of RBBB

A. True

B. False

True

False

0%0%

9/2/2015

8

The following ECG shows:

A. 1. Obvious

pacemaker malfunction

B. 2. Proper pacemaker function

1. Obvi

ous pace

mak

er m

alfu...

2. Pro

per pace

make

r funct

ion

0%0%

This patient has:

A. 1. Ventricular

Tachycardia

B. 2. An Acute MI

C. 3. Bundle Branch

Block

D. 4. Coronary Spasm

1. Ventr

icula

r Tach

ycard

ia

2. An A

cute

MI

3. Bundle

Bra

nch B

lock

4. Coro

nary S

pasm

0% 0%0%0%

9/2/2015

9

This patient has:

A. 1. Mobitz I

B. 2. Mobitz II

C. 3. Neither

1. Mobit

z I

2. Mobit

z II

3. Nei

ther

0% 0%0%

9/2/2015

10

This patient has:

A. 1. Mobitz I block

B. 2. Mobitz II block

C. 3. Can’t tell

1. Mobitz

I blo

ck

2. Mobitz

II b

lock

3. Can’t

tell

0% 0%0%

9/2/2015

11

This patient has:

A. 1. Mobitz I block

B. 2. Mobitz II block

C. 3. Can’t tell

1. Mobit

z I b

lock

2. Mobitz

II b

lock

3. Can

’t te

ll

0% 0%0%

9/2/2015

12

This patient has:

A. 1. Should be

immediately defibrillated

B. 2. Has clean teeth

C. 3. Should be sent to

the neurologist

1. Should

be im

media

tely

de...

2. Has c

lean

teeth

3. Should

be se

nt to th

e neu...

0% 0%0%

9/2/2015

13

This patient:

A. 1. Is having a cardiac

arrest

B. 2. Has a

disconnected ECG lead

C. 3. Needs a defibrillator

1. Is h

aving a

card

iac arr

est

2. Has a

dis

connect

ed ECG

lead

3. Needs

a defib

rilla

tor

0% 0%0%

45 y.o. M with C/P, 95% RCA Rx stent post EF 45% He needs:

A. 1. A life vest for 45

days then ICD

B. 2. Immediate ICD

implantation

C. 3. No life vest, no

ICD

1. A li

fe v

est fo

r 45 d

ays the...

2. Im

media

te IC

D im

planta

tion

3. No li

fe v

est, n

o ICD

0% 0%0%

9/2/2015

14

This patient:

A. 1. Had a recent viral infection and now presents with pleuritic chest pain

B. 2. Is having an MI

C. 3. Is a healthy black male with early repolarization pattern

1. Had a

rece

nt vira

l infe

ctio

...

2. Is h

aving an M

I

3. Is a

health

y bla

ck m

ale w

it...

0% 0%0%

This patient:

A. 1. Slow V-Tach

(Idioventricular rhythm)

B. 2. Is having an MI

C. 3. Has atrial

fibrillation and is having an MI

1. Slo

w V

-Tach

(Idio

ventricu...

2. Is havi

ng an M

I

3. Has

atria

l fib

rilla

tion a

nd ..

0% 0%0%

9/2/2015

15

This patient:

A. 1. Chest Pain

B. 2. A headache

1. Chest

Pain

2. A h

eadac

he

0%0%

9/2/2015

16

This patient:

A. 1. Chest Pain

B. 2. A headache

1. Chest

Pain

2. A h

eadac

he

0%0%

19 year old Black male collapsed playing basketball

A. 1. Benign

hypertrophy of healthy black males

B. 2. Has untreated HTN and LVH

C. 3. May have hypertrophic

cardiomyopathy1. B

enign h

ypertr

ophy of h

e...

2. Has

untreate

d HTN

and L

VH

3. May h

ave

hyper

trophic

c...

0% 0%0%

9/2/2015

17

This patient

A. 1. Is hyperkalemic

B. 2. Is having an MI

1. Is h

yperk

alem

ic

2. Is havi

ng an M

I

0%0%

9/2/2015

18

This patient

A. 1. Hyperkalemic

B. 2. Is having an acute

MI

1. Hyperk

alem

ic

2. Is havi

ng an a

cute

MI

0%0%

This patient

A. 1. Has hyperkalemia

B. 2. Is having an MI

1. Has

hyperkal

emia

2. Is h

aving a

n MI

0%0%

9/2/2015

19

This patient

A. 1. Has bulimia and

takes diuretics and laxatives

B. 2. Is hyperkalemic and needs dialysis

1. Has b

ulimia

and ta

kes diu

r...

2. Is h

yperkale

mic

and nee

ds...

0%0%

If the patient:A. 1. Develops Atrial

fibrillation give Sotolol and then cardiovert

B. 2. Develops pneumonia give erythromycin

C. 3. Develops a fungal infection give Ketaconozole

D. 4. Develops depression give Elavil

E. 5. None of the above1. D

evelops A

tria

l fib

rilla

tion...

2. Develo

ps p

neumonia

give...

3. Develo

ps a fu

ngal

infe

ctio

...

4. Develo

ps depre

ssio

n giv

e...

5. None o

f the a

bove

0% 0% 0%0%0%

9/2/2015

20

Causes of QT prolongation

A. 1. Congenital ion

channelopathies

B. 2. Drugs—Acquired

channelopathies

C. 3. Electrolyte

abnormalities

1. Congenita

l ion c

hannelop...

2. Dru

gs—Acq

uired ch

annel...

3. Ele

ctro

lyte

abnorm

alitie

s

0% 0%0%

9/2/2015

21

This arrhythmia originated in the:

A. 1. Atrium

B. 2. Ventricle

1. Atr

ium

2. Ven

tricle

0%0%

This patient

A. 1. Has V tach

B. 2. Has SVT (with

aberrancy)

1. Has V

tach

2. Has S

VT (with

aber

rancy

)

0%0%

9/2/2015

22

He has an EF of 35%, has been on ACEI and BB for 3month and subsequently has an ICD implanted. Which of the following are true:

A. 1. V tach may be terminated by anti tachy pacing

B. 2. V tach can be terminated by ICD shock

C. 3. The ICD can prevent Sudden Death by stopping a bullet

D. 4. All are true

1. V t

ach m

ay be te

rmin

ated...

2. V ta

ch can b

e term

inat

ed ..

3. The IC

D can p

reve

nt Sudd..

4. All

are tr

ue

0% 0%0%0%

ICD Therapies

Differentiating VTach from SVT with aberrancy

Width of QRS

Bizarre axis

AV dissociation

“Rabbit ears”

Concordant precordial QRS pattern

9/2/2015

23

This patient

A. 1. Needs a

pacemaker

B. 2. Needs a

defibrillator

1. Nee

ds a p

acem

aker

2. Nee

ds a d

efibril

lato

r

0%0%

9/2/2015

24

This patient

A. 1. Has a fever of 102

and sinus tachycardia

B. 2. Has SVT

1. Has a

feve

r of 1

02 and si

n..

2. Has S

VT

0%0%

This patient

A. 1. Has WPW

syndrome

B. 2. Has a Left Bundle

Branch Block

1. Has

WPW

syndro

me

2. Has a

Left

Bundle

Bra

nch ..

.

0%0%

9/2/2015

25

This patient

A. 1. Atrial fibrillation

B. 2. Ventricular

tachycardia

1. Atr

ial f

ibrilla

tion

2. Ven

tricula

r tach

ycard

ia

0%0%