ECG Review James T. DeVries, MD 6 December 2004

45 yo female 1 week post-op with shortness of breath The most likely diagnosis is: 1) ST elevation MI 2) Digitalis toxicity 3) Pulmonary embolism 4) Ventricular tachycardia

Findings Accelerated junctional rhythmAccelerated junctional rhythm Right axis deviationRight axis deviation “S1Q3T3” pattern“S1Q3T3” pattern Clinical history and EKG most consistent with acute PEClinical history and EKG most consistent with acute PE

67 yo dialysis patient without symptoms The most likely diagnosis is: 1) Pacemaker malfunction 2) Hyperkalemia 3) Normal EKG for dialysis patient 4) Intermittent LBBB

Findings NSR with 1rst degree AVBNSR with 1rst degree AVB injury current V1-V2injury current V1-V2 Peaked t wavesPeaked t waves Leftward axisLeftward axis Findings most c/wFindings most c/w hyperkalemia hyperkalemia

49 yo male with chest pain This EKG demonstrates 1) acute anterior infarction 2) acute inferior/posterior injury without RV involvement 3) acute inferior/posterior injury with RV involvement 4) acute pericarditis

Findings Sinus bradySinus brady inferior STEMIinferior STEMI posterior STEMIposterior STEMI V1 ST elevationV1 ST elevation Most consistent with inferior/posterior STEMI with RV involvementMost consistent with inferior/posterior STEMI with RV involvement

77 yo woman with hypertension This EKG demonstrates 1) 1)atrial flutter with 3:1 conduction 2) left ventricular hypertrophy 3) no abnormalities 4) left anterior fascicular block

Findings NSR with 1°AVBNSR with 1°AVB LVHLVH Best answer is LVHBest answer is LVH

Criteria for LVH Sokolow-LyonSokolow-Lyon Sv1+Rv5/v6>3.5mmSv1+Rv5/v6>3.5mm RI+SIII>2.5mmRI+SIII>2.5mm Ravl>11mmRavl>11mm CornellCornell Sv3+Ravl >2.8 (men)Sv3+Ravl >2.8 (men) >2.0 (women) >2.0 (women) Romhilt-EstesRomhilt-Estes LV strain 3LV strain 3 LAE 3LAE 3 LAD2LAD2 QRS duration 1QRS duration 1 R v5/v6>33R v5/v6>33 Sv1/v2>33Sv1/v2>33 Largest R or S>23Largest R or S>23 5 or more points suggests LVH

54 yo female with lung disease and shortness of breath The rhythm in this EKG is: 1)Ectopic atrial rhythm 2)NSR 3)Atrial bigeminy 4)Atrial flutter with block

Findings Ectopic rhythmEctopic rhythm Note PR>110msNote PR>110ms Inverted p wavesInverted p waves Best answer: Ectopic atrial rhythmBest answer: Ectopic atrial rhythm

22 yo male with lightheadedness and palpitation In addition to an echocardiogram, this patient will likely require: 1)A permanent pacemaker 2)A heart transplantation 3)A coronary angiogram 4)An ICD

Findings NSR with PAC’sNSR with PAC’s LVH with repoleLVH with repole Hypertrophic cardiomyopathy- altered myocyte shape, size, and alignment, leading to LVH, diastolic dysfunction, and syncope/sudden death. Frequently require prophylactic ICD placement when identified.Hypertrophic cardiomyopathy- altered myocyte shape, size, and alignment, leading to LVH, diastolic dysfunction, and syncope/sudden death. Frequently require prophylactic ICD placement when identified.

57 yo female with exercise-induced palpitations This patient presents to your ER with a BP of 100/60. She recently had a normal coronary angiogram and echo. The most likely diagnosis is: This patient presents to your ER with a BP of 100/60. She recently had a normal coronary angiogram and echo. The most likely diagnosis is: 1) Aberrant SVT 2) VT 3) Sinus tach with LBBB 4) Artifact

Findings A/V dissociationA/V dissociation LBBBLBBB Rightward axisRightward axis Positive QRSPositive QRS axis inferiorly axis inferiorly RV outflow tract ventricular tachycardia: typically catacholamine induced (post-exercise), have characteristic LBBB morphology with rightward axis and positive QRS vector inferiorly.RV outflow tract ventricular tachycardia: typically catacholamine induced (post-exercise), have characteristic LBBB morphology with rightward axis and positive QRS vector inferiorly.

25 yo male with systolic murmur The most likely diagnosis is: 1) Congenital bicuspid aortic valve 2) Severe mitral stenosis 3) Pulmonic stenosis 4) Ebstein’s anomaly

Findings RVHRVH Rightward axisRightward axis The constellation of right ventricular enlargement with rightward axis in a young patient with a systolic murmur is most suggestive of pulmonic stenosis.The constellation of right ventricular enlargement with rightward axis in a young patient with a systolic murmur is most suggestive of pulmonic stenosis.

Quick Review Right axis deviationRight axis deviation RVHRVH COPDCOPD Lateral MILateral MI LPFBLPFB Secundum ASDSecundum ASD RVHRVH R>7mm in V1 or R>10 with RBBBR>7mm in V1 or R>10 with RBBB Right axisRight axis S<2 in V1S<2 in V1 qR pattern in V1qR pattern in V1

32 yo male with palpitations This ECG demonstrates: 1) Wandering atrial pacemaker 2) Junctional rhythm 3) Delta waves 4) Subtle Epsilon waves

Findings NSR withNSR with short PR short PR Delta wavesDelta waves WPWWPW

45 yo male with palpitations The LEAST likely rhythm is: 1)AVNRT 2)Atrial flutter with 2:1 3)Multifocal atrial tachycardia 4)Orthodromic atrioventicular tachycardia

Findings Narrow complex, regular tachycardiaNarrow complex, regular tachycardia No visible p wavesNo visible p waves Multifocal atrial tachycardia requires >3 p wave morphologies and is slightly irregularMultifocal atrial tachycardia requires >3 p wave morphologies and is slightly irregular

The End