Some Interesting EKGs Justin Fox, MD Fellow in Cardiovascular Disease Northwestern Memorial Hospital Thank You: EKG Maven,

Asymptomatic 26yo …. Normal EKG (with possible T wave abnormality in III)

Method of EKG Interpretation Rate (300, 150, 100, 75, 60, 50) Rhythm (Is it NSR?) Axis (Normal -30 to +90) Intervals Chamber enlargement/hypertrophy q waves, ST segments, R wave progression, T waves, etc Pattern Recognition

Another asymptomatic 26yo… Ectopic atrial rhythm – look at p wave axis before deciding on sinus rhythm. A sinus P wave should be upright in inferior leads, and negative in aVR

47yo M w/ Chest Pain Anterior ST elevations, Tombstoning, reciprocal depressions inferiorly. Acute AWMI

Another 47yo M w/ Chest Pain Pericarditis, diffuse ST elevation, PR elevation aVR

47yo M w/ chest pain (R sided V1- V6) IWMI w/ posterior and RV involvement (STE in V4R), likely RCA infarct (STE in III greater than II suggests RCA more likely than LCx)

75yo M w/ Chest Pain Diffuse ST depressions with ST elevation in aVR. This suggests global ischemia – i.e. 3v dz or L main disease

32yo asymptomatic man Wolff-Parkinson-White Syndrome

What Could Happen to That Guy AF w/ Treat w/ Procainamide, which slows conduction thru bypass tract. (This EKG is on the internal medicine boards)

Another interesting 32yo M Brugada Syndrome – RBBB type pattern with ST elevations V1-2. Sodium channelopathy, associated with sudden death.

What Might Happen to This Guy

69yo F w/ Dyspnea and Clear CXR Sinus Tachycardia w/ S1Q3T3 pattern suggestive of PE

What’s the rhythm? Sinus rhythm w/ motion artifact due to Parkinson’s Disease. Note “flutter waves” only seen in leads that use R arm lead (and V1). Pt’s tremor is worse on right.

What’s the Rhythm? Left leg tremor 2/2 CVVHD artifact (vascath in L femoral vein). “Flutter” went away when CVVH machine was paused. Also low voltage QRS.

74yo F….. RBBB with a L axis due to L anterior fascicular block (qR in I and aVL, rS in III). This is bifascicular block

How is this one different? Same as prior but now w/ PR prolongation. This is “trifascicular block” – either left posterior fascicle is slow or AV node disease

What’s Wrong With This Patient’s Dual Chamber Pacemaker? V-paced w/ RBBB pattern. PPM perforated septum, pacing now coming from LV cavity. (This is also seen with a normally functioning BiV pacer).

80yo M w/ longstanding AFib AF w/ CHB and Junctional escape, Dig toxicity

What’s This? Bidirectional VT, Dig toxicity

Huh? Ghany R and de Marchena E. N Engl J Med 2007;356:e6 2 hearts – heterotopic heart transplant with native heart left in position.

Some Extras….

And another asymptomatic 26yo… Limb lead reversal (neg p and neg QRS in I), aVL looks like aVR should, also sinus arrhythmia

#1=AV Wenckebach (4:3, then 3:2); #2=SA Wenckeach (4:3); #3=Pacemaker Wenckebach Rhythm Strips From 3 Different Patients

Patel A and Getsos J. N Engl J Med 1994;330:680 What’s The Rhythm?

Saadlla H. N Engl J Med 2004;351:e4 A better look at Osborn Waves

What’s the Lab Abnormality? Hyperkalemia