ECG ReviewECG Review

James T. DeVries, MDJames T. DeVries, MD

6 December 20046 December 2004

45 yo female 1 week post-op with shortness of breath

The most likely diagnosis is:

1) ST elevation MI

2) Digitalis toxicity

3) Pulmonary embolism

4) Ventricular tachycardia

FindingsFindings

• Accelerated Accelerated junctional rhythmjunctional rhythm

• Right axis deviationRight axis deviation• ““S1Q3T3” patternS1Q3T3” pattern

• Clinical history and Clinical history and EKG most consistent EKG most consistent with acute PEwith acute PE

67 yo dialysis patient without symptoms

The most likely diagnosis is:

1) Pacemaker malfunction

2) Hyperkalemia

3) Normal EKG for dialysis patient

4) Intermittent LBBB

FindingsFindings

• NSR with 1rst degree NSR with 1rst degree AVBAVB

• injury current V1-V2injury current V1-V2• Peaked t wavesPeaked t waves• Leftward axisLeftward axis

• Findings most c/wFindings most c/w

hyperkalemiahyperkalemia

49 yo male with chest pain

This EKG demonstrates

1) acute anterior infarction

2) acute inferior/posterior injury without RV involvement

3) acute inferior/posterior injury with RV involvement

4) acute pericarditis

FindingsFindings

• Sinus bradySinus brady• inferior STEMIinferior STEMI• posterior STEMIposterior STEMI• V1 ST elevationV1 ST elevation

• Most consistent with Most consistent with inferior/posterior STEMI inferior/posterior STEMI with RV involvementwith RV involvement

77 yo woman with hypertension

This EKG demonstrates

1) atrial flutter with 3:1 conduction

2) left ventricular hypertrophy

3) no abnormalities

4) left anterior fascicular block

FindingsFindings

•NSR with 1°AVBNSR with 1°AVB

•LVHLVH

•Best answer is LVHBest answer is LVH

Criteria for LVHCriteria for LVH

• Sokolow-LyonSokolow-Lyon• Sv1+Rv5/v6>3.5mmSv1+Rv5/v6>3.5mm• RI+SIII>2.5mmRI+SIII>2.5mm• Ravl>11mmRavl>11mm

• CornellCornell• Sv3+Ravl >2.8 (men)Sv3+Ravl >2.8 (men)

>2.0 (women)>2.0 (women)

• Romhilt-EstesRomhilt-Estes• LV strain LV strain 33• LAE LAE 33• LADLAD 22• QRS duration QRS duration 11• R v5/v6>3R v5/v6>3 33• Sv1/v2>3Sv1/v2>3 33• Largest R or S>2Largest R or S>2 33

5 or more points suggests LVH5 or more points suggests LVH

54 yo female with lung disease and shortness of breath

The rhythm in this EKG is:The rhythm in this EKG is:

1)1) Ectopic atrial rhythmEctopic atrial rhythm

2)2) NSRNSR

3)3) Atrial bigeminyAtrial bigeminy

4)4) Atrial flutter with blockAtrial flutter with block

FindingsFindings

• Ectopic rhythmEctopic rhythm• Note PR>110msNote PR>110ms• Inverted p wavesInverted p waves

• Best answer: Ectopic Best answer: Ectopic atrial rhythmatrial rhythm

22 yo male with lightheadedness and palpitation

In addition to an echocardiogram, this patient will likely require:In addition to an echocardiogram, this patient will likely require:

1)1) A permanent pacemakerA permanent pacemaker

2)2) A heart transplantationA heart transplantation

3)3) A coronary angiogramA coronary angiogram

4)4) An ICDAn ICD

FindingsFindings

• NSR with PAC’sNSR with PAC’s• LVH with repoleLVH with repole

• Hypertrophic cardiomyopathy- altered myocyte Hypertrophic cardiomyopathy- altered myocyte shape, size, and alignment, leading to LVH, shape, size, and alignment, leading to LVH, diastolic dysfunction, and syncope/sudden death. diastolic dysfunction, and syncope/sudden death. Frequently require prophylactic ICD placement Frequently require prophylactic ICD placement when identified.when identified.

57 yo female with exercise-induced palpitations

This patient presents to your ER with a BP of 100/60. She This patient presents to your ER with a BP of 100/60. She recently had a normal coronary angiogram and echo. The recently had a normal coronary angiogram and echo. The most likely diagnosis is:most likely diagnosis is:

1) Aberrant SVT1) Aberrant SVT

2) VT2) VT

3) Sinus tach with LBBB3) Sinus tach with LBBB

4) Artifact4) Artifact

FindingsFindings• A/V dissociationA/V dissociation• LBBBLBBB• Rightward axisRightward axis• Positive QRSPositive QRS

axis inferiorlyaxis inferiorly

• RV outflow tract ventricular tachycardia: typically RV outflow tract ventricular tachycardia: typically catacholamine induced (post-exercise), have catacholamine induced (post-exercise), have characteristic LBBB morphology with rightward axis characteristic LBBB morphology with rightward axis and positive QRS vector inferiorly.and positive QRS vector inferiorly.

25 yo male with systolic murmur

The most likely diagnosis is:The most likely diagnosis is:

1) Congenital bicuspid aortic valve1) Congenital bicuspid aortic valve

2) Severe mitral stenosis2) Severe mitral stenosis

3) Pulmonic stenosis3) Pulmonic stenosis

4) Ebstein’s anomaly4) Ebstein’s anomaly

FindingsFindings

• RVHRVH• Rightward axisRightward axis

• The constellation of The constellation of right ventricular right ventricular enlargement with enlargement with rightward axis in a rightward axis in a young patient with a young patient with a systolic murmur is most systolic murmur is most suggestive of pulmonic suggestive of pulmonic stenosis.stenosis.

Quick ReviewQuick Review

• Right axis deviationRight axis deviation• RVHRVH• COPDCOPD• Lateral MILateral MI• LPFBLPFB• Secundum ASDSecundum ASD

• RVHRVH• R>7mm in V1 or R>7mm in V1 or

R>10 with RBBBR>10 with RBBB• Right axisRight axis• S<2 in V1S<2 in V1• qR pattern in V1qR pattern in V1

32 yo male with palpitations

This ECG demonstrates:This ECG demonstrates:

1) Wandering atrial pacemaker1) Wandering atrial pacemaker

2) Junctional rhythm2) Junctional rhythm

3) Delta waves3) Delta waves

4) Subtle Epsilon waves 4) Subtle Epsilon waves

FindingsFindings

• NSR withNSR with

short PRshort PR• Delta wavesDelta waves

• WPWWPW

45 yo male with palpitations

The LEAST likely rhythm is:The LEAST likely rhythm is:

1)1) AVNRTAVNRT

2)2) Atrial flutter with 2:1Atrial flutter with 2:1

3)3) Multifocal atrial tachycardiaMultifocal atrial tachycardia

4)4) Orthodromic atrioventicular tachycardiaOrthodromic atrioventicular tachycardia

FindingsFindings

• Narrow complex, regular tachycardiaNarrow complex, regular tachycardia• No visible p wavesNo visible p waves

• Multifocal atrial tachycardia requires >3 p Multifocal atrial tachycardia requires >3 p wave morphologies and is slightly irregularwave morphologies and is slightly irregular

The EndThe End