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 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. QRS duration > 0.12 second 2. A wide deep QS complex in V1 3. A wide tall R wave in V6 The correct answer is d) There is no left bundle branch block (LBBB)
LVH 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 5. Voltage criteria for left ventricular hypertrophy (LVH) should be used with caution. Commonly used voltage criteria include one or 1. SV1 + RV5 or 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)
Case two A 26-year-old woman comes to the emergency department complaining of increased shortness of breath. Which one of the following statements is true concerning her admission ECG? 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
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 1. RAD- axis is perpendicular to AVF~180 2. qR in V1 3. ST-T changes in V1-V4 in keeping with RV strain pattern Correct Answer is e
RV hypertrophy occurs over time in response to pressure or volume overload in conditions such as; 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.
What would you do? 1. Urgent hospital admission for coronary arteriography 2. Urgent angiographic CT scan to exclude pulmonary embolism 3. Consider this ECG as a normal variant and reassure the patient accordingly 4. Nothing, this is a typical artifact originating from a poor connection of the Wilson terminal to the ground 5.None of the above
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 obtained a routine ECG 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
cMR
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.
What would you do first? 1.Chest X ray 2.2D ECHO 3.Holter recording 4.CT scan 5.Cardiac MRI
Case 5: This ECG from an 18 year old male shows all of the following EXCEPT? a) Normal variant early repolarization pattern b) Physiologic sinus arrhythmia c) Normal AV conduction d) Left axis deviation e) Transition zone in lead V3
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.
Case 6 This ECG from a 23 year-old female is most consistent with which diagnosis? a) Left atrial abnormality b) Anterior ischemia c) Normal variant T wave inversions V1-V2 d) Hypokalemia e) Left ventricular hypertrophy
a) Left atrial abnormality b) Anterior ischemia c) Normal variant T wave inversions V1-V2 d) Hypokalemia e) Left ventricular hypertrophy
ECG manifestations of acute myocardial ischemia • ST elevation 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. • ST depression and T-wave changes 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.
ECG infarct
Common causes of ST shift
Infarct localisation • Left main artery occlusion: diffuse ST-depression with ST o elevation in AVR very high risk o • Anterior wall: ST elevation V1-V4. LAD. (often o tachycardia) • Inferior wall : ST elevation II, III, AVF. o 80% RCA (elevation III>II; depression o > I or in AVL) , or RCX ( in 20%). (often bradycardic due to sinus node or AV node ischemia) • Right ventricle infarct: ST elevation in V4R . o • Posterior wall : high R and ST-depression in V1-V3 o • Lateral wall: ST elevation in lead I, AVL, V6. o LAD (D-branch) o
V4 right helps diagnose right ventricular involvement (in RCA occlusion)
Acute inferior MI
Old inferior MI: prominent Q waves in II, III & AVF
Acute anterior-lateral infarct
Acute antero-septal MI
Recent (days old) anterior MI (after PCI)
Old anterior-septal MI
Acute posterior MI more about this topic on ECGpedia...
Acute RCX occlusion Notice the rather typical relative absence of ST deviation.
Old/recent posterior-lateral MI prominent R in V2 (a 'reciprocal Q wave')
Acute inferior-posterior-lateral MI
Acute inferior and right ventricular MI Elevation of V4R
Left main disease Diffuse ST depression and elevation in AVR
ST elevation in the absence of an aMI Some other conditions that can cause ST elevation are: • Pericarditis/myocarditis. • Left ventricular hypertrophy (LVH) • Physiological/benign ST elevation • Cardiac aneurysm • Hyperkalemia • LBBB • HCM
ST elevation in LBBB
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
ST elevation in LVH
ST elevation during high potassium levels
Diffuse ST elevation in pericarditis
Non-ST Elevation Infarction Here ’ s an ECG of an evolving non-ST elevation MI: Note the ST depression and T-wave inversion in leads V 2 -V 6 . Question: What area of the heart is infarcting? Anterolateral
Bundle Branch Blocks
Bundle Branch Blocks Turning our attention to bundle branch blocks… Remember normal impulse conduction is SA node AV node Bundle of His Bundle Branches Purkinje fibers
Normal Impulse Conduction Sinoatrial node AV node Bundle of His Bundle Branches Purkinje fibers
Bundle Branch Blocks So, depolarization of the Bundle Branches and Purkinje fibers are seen as the QRS complex on the ECG. Therefore, a conduction block of the Bundle Branches would be Right reflected as a change in BBB the QRS complex.
Bundle Branch Blocks With Bundle Branch Blocks you will see two changes on the ECG. 1. QRS complex widens (> 0.12 sec). 2. QRS morphology changes (varies depending on ECG lead, and if it is a right vs. left bundle branch block).
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