ECG%20Practice%20Cases:%20Part%201

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ECG Practice CasesPart 1

• Megan Chan, PGY-1
• UHCMC 2015

http//thepracticalpsychosomaticist.com/2013/04/01
/qtc-interval-prolongation-and-antipsychotics-by-e
lysha-elson-pharm-d-mph/
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77 y/o male with BP 170/95
DIAGNOSIS?
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What Can Cause This ECG Change?
NSR with LVH repolarization abnormality (R in
I gt 14, R in aVL gt 12, S in V2 R in V5 gt
35) LVH strain shown as ST depression and T wave
inversion in anterolateral leads (I, aVL, V5 or
V6)
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Left Ventricular Hypertrophy

• Etiology
• Chronic HTN
• Aortic stenosis
• Aortic insufficiency
• Long-standing CAD
• Some forms of congenital heart disease

http//www.wikidoc.org/index.php/Aortic_stenosis_m
icroscopic_pathology
http//www.crc-erlangen.de/methods/index.html
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54 y/o female admitted for stroke
DIAGNOSIS?
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What Can Cause LAE?
NSR with R axis deviation (down in I) Left atrial
enlargement (p gt 120ms, M-shaped in II) Old
septal infarct (Q waves in V1 V2) Low Voltage
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Left Atrial Enlargement

• Etiology
• Mitral stenosis
• Mitral regurgitation
• LVH
• Atrial fibrillation

http//ecg.utah.edu/lesson/7
https//www.youtube.com/watch?vgGz0T_dw0Ho
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80 y/o female with DOE
DIAGNOSIS?
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NSR with RBBB Left anterior fascicular block
(left axis deviationdown in II, up in I)
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http//www.usfca.edu/fac-staff/ritter/Image74.gif
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What Can Cause RBBB?
NSR with RBBB Left anterior fascicular block
(left axis deviationdown in II, up in I) (RSR
in V1, broad S in V6)
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Right Bundle Branch Block

• Etiology
• Pulmonary HTN
• ASD
• Ischemia
• PE
• Acute exacerbation of COPD

http//research.vet.upenn.edu/smallanimalcardiolog
y/ECGTutorial/AbnormalECGs/tabid/4960/Default.aspx
http//en.wikipedia.org/wiki/Right_bundle_branch_b
lock
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96 y/o female with new chest pain
DIAGNOSIS?
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DIAGNOSIS?
NSR with Anterior STEMI (ST elevations in V2-V4,
Reciprocal ST depressions in II, III, aVF) LVH (S
in V2 R in V6 gt35) LAE (P gt 3 small boxes,
diphasic in V1)
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Location Leads Occluded Vessel
Anterior V2-V4 LAD
Anteroseptal V1-V4 LAD
Anterolateral V1-V6, I, aVL LAD, diagonal
Lateral V5-V6, I, aVL Circumflex, diagonal
Inferior II, III, aVF RCA, circumflex
Posterior Tall R in V1-V3, ST depression in V1-V2 RCA
http//www.edoctoronline.com/media/19/photos_245a9
75b-66ad-4f7e-86d8-82d3ca7d0120.jpg
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Reciprocal Changes in MI
Loss of R wave progression
http//www.emedu.org/ecg/crapsanyallans.php
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Right Ventricular Infarction
http//www.emedu.org/ecg/crapsanyallans.php
http//www.ems12lead.com/2008/10/17/12-lead-ecg-le
ad-placement-diagrams/
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Summary of ECG Changes in MI
Location of MI Presence of Q wave or ST elevation Reciprocal ST depression
Anterior V1-V6 loss of R wave progression II, III, aVF
Lateral I, aVL, V5, V6 V1, V3
Inferior II, III, aVF I, aVL, possibly anterior leads
Posterior Abnormally tall R T waves in V1-V3 V1-V3
Subendocardial No abnormal Q waves
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DDX for ST segment elevations

• Ischemia
• Acute MI
• Prinzmetals angina
• Post MI (ventricular aneurysm)
• Acute pericarditis
• LVH/LBBB

• Rarer Causes
• Class 1C antiarrhythmic drugs
• Hypercalcemia
• Hyperkalemia
• Hypothermia
• Brugada pattern
• DC cardioversion
• Myocardial injury
• Myocarditis
• LV tumor
• Trauma to ventricles

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79 y/o female with CAD
DIAGNOSIS?
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What can Cause LBBB?
NSR with LBBB (deep S in V1, inverted T in V6)
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Left Bundle Branch Block

• Etiology
• HTN
• Ischemia
• Valvular heart disease
• Severe aortic stenosis

http//research.vet.upenn.edu/smallanimalcardiolog
y/ECGTutorial/AbnormalECGs/tabid/4960/Default.aspx
http//en.wikipedia.org/wiki/Left_bundle_branch_bl
ock
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REFERNCES

• Agabegi SS, Agabegi ED. Step up to Medicine, 3rd
  ed. 2013. Lippincott Williams Wilkins.
  Philadelphia, PA.
• Gomella LG, Haist SA. Basic EKG reading. In
  Clinicians Pocket Reference. McGraw-Hill 2007.
  http//flylib.com/books/en/2.569.1.27/1/.
  Accessed Nov 18, 2014.
• Longo DL, Fauci AS, Kasper DL, et al.
  Electrocardiography. In Harrisons Principles of
  Internal Medicine, 18th ed. 2012. McGraw Hill.
  New York, NY.
• University of Illinois at Chicago. Online ICU
  Guidebook. 2013. http//chicago.medicine.uic.edu/U
  serFiles/Servers/Server_442934/Image/1.1/residentg
  uides/final/icuguidebook.pdf. Accessed December
  1, 2014.