SHIVDA PANDEY, PGY-6 MARK VILLALON, PGY-6 BOSTON MEDICAL CENTER CARDIOVASCULAR FELLOWS ECG Master Session SENIOR RESIDENT EDITION

What is your ECG diagnosis? PCP Clinic Visit  65 year old male with PMH hypertension and active smoking is in your clinic for an initial evaluation.  He has no complaints and feels well.  Routine ECG is performed in light of his cardiac risk factors and reveals the following:

What is your diagnosis? A. I know the diagnosis and can teach this concept to my 3 rd year med student B. I’m pretty sure about this diagnosis C. I’m not very sure about this diagnosis D. What does the automated read say?

Diagnosis Step 1: Normal sinus rhythm ** Always start with the rhythm**

“NSR is not “There’s a P before every QRS” “There’s a P before every QRS”  This does not define NSR  Can be seen in flutter, a-tach etc Sinus rhythm = Upright P’s in:  Lead I, II and aVF Right to left activation

Diagnosis 1. NSR 2. Wow, is that QRS wide or something?

Sinus rhythm and the wide QRS 100 msec120 msec  Normal QRS width  IVCD  “Incomplete RBBB”  “Incomplete LBBB”  LBBB  RBBB  IVCD

South Shore Plaza FastSlow

LBBB: RV contracts, then LV contracts V6

Left Bundle Branch Block QRS > 120 msec V5-V6: Broad R wave I + aVL: Absence of Q wave

RBBB: Left ventricle contracts, then right ventricle contracts QRS > 120 msec V1-V2: RSR’ Lateral leads: Deep terminal S wave

A. IVCD B. RBBB C. LBBB

A. IVCD B. RBBB C. LBBB

A. IVCD B. RBBB C. LBBB

“When I go fast, I go wide” Rate-related aberrancy  Usually RBBB, but can be LBBB  Refractoriness  Clinical significance: At faster rates, need to differentiate VT vs SVT with aberrancy

PA catheter insertion Pt with LBBB Complete heart block. Hopefully there’s an escape rhythm. Watch the monitor during insertion.

55M with PMH DM2 and smoking p/w 1hr of “crushing” chest pain. ECG from last week with NSR and normal QRS width. Dx? Mx? A. New LBBB. Wait for the enzymes. B. New LBBB. Admit to Obs unit. C. New LBBB. Call cards fellow to activate the cath lab STAT.

55M with PMH DM2 and smoking p/w 1hr of “crushing” chest pain. ECG from last week with NSR and normal QRS width. Dx? Mx? A. Old LBBB. Wait for the enzymes. B. Old LBBB. Admit to Obs unit. C. Old LBBB + acute MI. Call cards fellow STAT. D. This is a trick question.

Discordant: QRS deflection is opposite of T wave deflection Concordant: QRS deflection is the same of T wave deflection Normal in LBBB and paced rhythm

How to diagnose an acute MI in pt with LBBB (or paced rhythm) ST elevation ≥1 mm in a lead with upward (concordant) QRS complex - 5 points ST elevation ≥5 mm in a lead with downward (discordant) QRS complex - 2 points ST depression ≥1 mm in lead V1, V2, or V3 - 3 points ≥3 points = 90% specificity of STEMI (sensitivity of 36%)

Thank you