Cardiology ECG Review for the ABIM

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Cardiology ECG Reviewfor the ABIM
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• A 42-year-old man is noted to have a soft S1 on
  physical examination.

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2. Look at QRS3. Assess ST Segment
Wheres The P
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• A 72-year-old man with a 35-year history of
  hypertension is evaluated because of dyspnea.

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What is LVH?

• Cornell
• R wave in aVL S wave in V3
• gt20 in ?, gt24 in ?
• Voltage
• R wave in V5/V6 S in V1 gt 35mm
• Non Voltage Changes
• LAA
• LAD
• IVCD
• Asymmetric ST depression T wave inversion

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A 72-year-old man is noted to have bradycardia
alternating with tachycardia during an orthopedic
procedure.
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ECG Diagnosis

• Atrial fibrillation (AF) is characterized by
• 1. Rapid and irregular atrial fibrillatory waves
  at a rate of 350 to 600 imp/min
• 2. An irregularly irregular ventricular response
  of 90 up to 170 beats/min
• (Can be higher in some pts)

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Pitfalls in Diagnosis

• 1. Fibrillatory waves may be inapparent on the
  standard and precordial leads.
• 2. Fibrillatory and U waves may have sufficient
  amplitude to look like P waves.
• 3. Extracardiac artifacts (eg, 60 cycle/min
  muscle tremors as in Parkinsonism) may simulate
  fibrillatory waves.
• 4. Regular R-R interval with AV dissociation or
  block with a lower junctional or ventricular
  pacemaker assumes control of the ventricles

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• A 65-year-old woman is evaluated because of
  new-onset atrial fibrillation and an embolic
  stroke. Echocardiography is performed. What does
  the echocardiogram show?

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Spontaneous Echo Contrast

• Increased RBC aggregation due to altered LAA flow
  dynamics and uncoordinated left atrial systole
• Results in smoke-like echoes swirling in LA SEC
  or smoke presumed to proceeding stage to
  thrombus formation
• Seen in 50- 65 of pts with AF

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60-year-old woman with hypertension and
diabetes mellitus is evaluated because of an
8-hour history of substernal chest pressure
associated with dyspnea and diaphoresis.
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MI - LOCATION

• Anteroseptal V1-3
• Inferior II, III, F
• Anterior V2-4, or V1-V6
• Anterolateral V4/5-V6, I, aVL
• Right Ventricular ST elevation V4R
• Posterior Tall R waves in V1, R/S ratio in
  V1gt1

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• Normal ST elevation (concave)

Early repolarization (concave)

• Normal variant with terminal T-wave inversion

Marriott, NEJM, 2004.
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LVH
LBBB
Brugada
HyperK
AS MI
AS RBBB
Acute Pericarditis
Marriott, NEJM, 2004.
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• A 38-year-old woman is evaluated because of
  palpitations. She has a childhood history of the
  acute onset of rapid regular palpitations that
  she has learned to terminate with different vagal
  maneuvers. A 12-lead electrocardiogram taken
  during a period of palpitations is shown. What
  abnormality is seen?

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Commonly Encountered SVT

• Regular
• Sinus Tachycardia
• PSVT
• AVRT
• AVNRT
• SART
• Atrial Flutter
• PAT

• Irregular
• Atrial Fibrillation
• MAT
• Sinus Tachycardia with frequent PACs
• Atrial Flutter with variable AV block

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AVNRT

• Most common SVT
• Two pathways within the AV node
• Rates 120-250BPM
• Median age 32/-18
• P waves often buried within QRS complex
• Inverted P waves in leads I, II, III and aVF
• Pseudo-r waves in V1

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AVNRT
lt70ms
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• A 76-year-old woman with hypertension and
  paroxysmal atrial fibrillation is seen for a
  follow-up visit. Current medications are
  hydrochlorothiazide and digoxin.

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Digitalis Toxicity

• Classic combo disturbances
• Atrial tachycardia with AV block
• Regular, accelerated junctional rhythm in AF

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• A 65-year-old man is evaluated because of
  lower-extremity edema and renal failure.
  Echocardiography is performed. What does the
  echocardiogram show?

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• A 75-year-old woman who was treated for heart
  block 3 years ago is seen for a follow-up visit.

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Pacemaker Codes
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Pacing Systems
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Pacemaker
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• An 87-year-old man with a pacemaker implanted for
  atrioventricular block is seen in follow-up.

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• An 80-year-old man underwent implantation of a
  single-chamber pacemaker for paroxysmal
  atrioventricular block 3 years ago. He now has a
  cerebrovascular accident.

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VVI Mode

• Responds to a sensed event.
• Time value remaining in interval deleted
• Output circuit disabled
• Interval ends without a paced event
• Commonly used for patients in chronic AF.

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VVI Mode

1. Ventricular pacing
2. Ventricular pacing after ventricular escape
   interval(VV)
3. Ventricular sensed event, no pacing, VV reset
4. Ventricular pacing after reset ventricular escape
   interval

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• A 60-year-old woman is evaluated because of
  palpitations.

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Atrial Flutter

• Atrial tachycardia typicallylt 180 bpm
• AT usually has isoelectric baseline
• Atrial fluttter rates 240-200 bpm
• Macroreentrant atrial rhythm with a reentry
  circuit involving large area of atrium
• Commonly 21 AV conduction
• Even ratios (21, 41) much more common than odd
  ratios (31, 51)

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Atrial Flutter

• Type I or Typical atrial flutter
•   

• Type II
• atrial flutter

More negative in Lead II
More positive F waves inferiorly
M
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• A 59-year-old man is brought to the emergency
  department because of substernal chest pressure
  of 1 hour's duration.

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Heart Block in MI

• Inferior MI
• Anterior MI

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• A 53-year-old woman is evaluated because of
  pleuritic chest pain.

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Classic Evolution in Acute Pericarditis

• Stage 1 Concave ST segment elevation in almost
  all leads (no reciprocal ST depression)
• Stage 2 ST segments decrease and T wave
  amplitude reduces
• Stage 3 T waves invert
• Stage 4 ECG normalizes

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Acute Pericarditis

• Look at lead aVR
• ST depression
• PR elevation
• Sinus Tachycardia
• PR depression
• Look for electrical alternans

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• An 84-year-old woman is hospitalized because of
  acute coronary syndrome.

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• A 74-year-old man with ischemic cardiomyopathy
  and an implanted cardioverter/defibrillator
  develops palpitations and presyncope.

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VT- All favor

• History 90 of Ischemic CMP WCTVT
• Axis- northwest/ right superior
• QRS Duration
• RBBBgt 140ms
• LBBBgt 160ms
• Precordial Concordance (esp negative)
• AV Dissociation
• Fusion beats
• Capture beats

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• A 78-year-old woman is hospitalized because of
  pyelonephritis.

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• A 50-year-old man with severe ischemic
  cardiomyopathy is hospitalized because of
  syncope.

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Bundle Branch Block QRSgt 0.12ms

• Left
• Broad monophasic R wave in leads I, V5, or V6
• Leads V1-2 reveal QS or rS pattern
• Right
• Secondary r wave in V1 o ften an M shape
• Wide slurred S wave in I, V5, and V6

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• A 60-year-old man with hypertension and an
  evolving anterior wall myocardial infarction is
  evaluated in the emergency department.

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• Acquired Polymorphic VT most commonly
  precipitated by long-short RR intervals

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• A 45-year-old male smoker is evaluated because of
  a 3-hour history of substernal chest pressure
  radiating to the left arm associated with nausea
  and vomiting.

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A 43-year-old man with congenital heart disease
is evaluated because of progressive dyspnea for
the past 3 years.
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RVH

• Right axis deviation
• Tall R wave in V1gt 7mm, R/S ratio V1gt 1
• QRSlt 120ms
• S wave in in V5/6gt 2mm

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• A 44-year-old woman has hypertension.

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AVRT
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AVRT
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Bypass Tract
BPT is concealed, retrograde conduction allows
Atrial activationgtgtAVN conductiongtgtV activationgtgt
Retrograde BPT conductiongtgt Atrial activation ..
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Bypass Tract
Antegrade conduction is evidenced by Delta wave,
atrial activationgtgt BPT conductiongtgt V
activationgtgt Retrograde AVN conduction gtgt atrial
activation ..
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AVRT
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• A 52-year-old man is evaluated because of acute
  renal insufficiency

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• An otherwise asymptomatic 72-year-old man is
  evaluated because of an irregular pulse rate
  detected by his physician.

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• A 55-year-old man is evaluated because of chest
  pain and hypotension 5 days after sustaining a
  myocardial infarction. Echocardiography is
  performed.
• What does the echocardiogram show?

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• A 22-year-old man is evaluated because of
  dyspnea.

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• A 74-year-old man is evaluated because of
  exertional fatigue.

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Heart Block

• Complete Heart Block
• AV dissociation
• No relationship between P waves and QRS complexes
• RR is regular
• Second degree AV block Mobitz Type II
• PR remains constant and is either nml or slighlt
  prolonged
• Ventricular rhythm is irregular because of
  nonconducted beats

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• 62-year-old man with hypertension and diabetes
  mellitus is evaluated because of substernal chest
  pressure radiating to the neck for the past 35
  minutes. A 12-lead electrocardiogram is obtained
  upon his arrival in the emergency department.

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• A 70-year-old woman with hypertension is seen for
  evaluation.

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• A 40-year-old woman is evaluated because of
  headaches and muscle cramps.

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A 46-year-old woman is evaluated because of
palpitations. Her 12-lead electrocardiogram,
obtained while she is having typical symptoms.
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• A 74-year-old man with a history of prior
  myocardial infarction is evaluated because of
  palpitations.