ECG Practice Cases: Part 3—Special Cases Megan Chan, PGY-1 UHCMC 2015 Torsades picture: http://thepracticalpsychosomaticist.com/2013/04/01/qtc-interval-prolongation-and-antipsychotics-by-elysha-elson-pharm-d-mph/ http://thepracticalpsychosomaticist.com/2013/04/01/qtc-interval-prolongation-and-antipsychotics-by-elysha-elson-pharm-d-mph/

84 y/o female with syncope DIAGNOSIS? #39 Sinus bradycardia, HR 40. Tx: pacemaker placed Possible LAE Low voltage QRS (consider pulm disease, pericardial effusion, obesity, myocarditis 2/2 less activated muscle) Incomplete RBBB

What Causes Low Voltage QRS? #39 Sinus bradycardia, HR 40. Tx: pacemaker placed Possible LAE Low voltage QRS (consider pulm disease, pericardial effusion, obesity, myocarditis 2/2 less activated muscle) Incomplete RBBB Sinus Bradycardia (HR 40) with Low Voltage QRS Incomplete RBBB (RSR’ in V1 but no deep S in V6)

Low Voltage QRS Amplitude of QRS is < 5mm in limb leads & < 10mm in precordial leads Etiology Pericardial effusion Hyperinflation of lungs (e.g. COPD, pneumothorax) Pericarditis (2/2 less activated muscle) Obesity Generalized edema Severe ischemic disease Infiltrative diseases (e.g. amyloidosis) Thyroid disease Pleural effusion Post-open heart surgery

What Treatment Would You Recommend? #39 Sinus bradycardia, HR 40. Tx: pacemaker placed Possible LAE Low voltage QRS (consider pulm disease, pericardial effusion, obesity, myocarditis 2/2 less activated muscle) Incomplete RBBB Sinus Bradycardia (HR 40) with Low Voltage QRS Incomplete RBBB (RSR’ in V1 but no deep S in V6)

What Treatment Would You Recommend? #39 Sinus bradycardia, HR 40. Tx: pacemaker placed Possible LAE Low voltage QRS (consider pulm disease, pericardial effusion, obesity, myocarditis 2/2 less activated muscle) Incomplete RBBB Pacemaker Placement

Indications for Cardiac Pacemakers Sinus node dysfunction Mobitz Type II heart block Complete heart block Symptomatic bradyarrhythmias Tachyarrhythmias (e.g. recurrent/sustained SVT) Hypersensitive carotid sinus syndrome Sinus node dysfunction = most common indication Indications for ICD Therapy Class I 1. Cardiac arrest due to VF or VT not due to a transient or reversible cause. (Level of evidence: A) 2. Spontaneous sustained VT. (Level of evidence: B) 3. Syncope of undetermined origin with clinically relevant, hemodynamically significant sustained VT or VF induced at electrophysiological study when drug therapy is ineffective, not tolerated, or not preferred. (Level of evidence: B) 4. Nonsustained VT with coronary disease, prior MI, LV dysfunction, and inducible VF or sustained VT at electrophysiological study that is not suppressible by a Class I antiarrhythmic drug. (Level of evidence: B) http://www.circ.ahajournals.org/content/97/13/1325.full

65 y/o male at a follow up visit DIAGNOSIS? #44 Sinus rhythm with occasional PVC, HR 75 Ventricular pacing (usually LBBB pattern unless biventricular pacing then can be RBBB pattern) *If p waves are present, this means atrial tracking and ventricular pacing is occurring.

Ventricular pacing with PVC (P waves indicate atrial tracking, Pacer spikes #44 Sinus rhythm with occasional PVC, HR 75 Ventricular pacing (usually LBBB pattern unless biventricular pacing then can be RBBB pattern) *If p waves are present, this means atrial tracking and ventricular pacing is occurring. Ventricular pacing with PVC (P waves indicate atrial tracking, LBBB pattern typical unless biventricular pacing)

Compared to… Atrial pacing http://commons.wikimedia.org/wiki/File:Brady-tachy_syndrome_atrial_pacing.png

Atrial Pacing Normal QRS interval Atrial pacing http://commons.wikimedia.org/wiki/File:Brady-tachy_syndrome_atrial_pacing.png

59 y/o female with SOB DIAGNOSIS? #42 NSR, HR 65 Left posterior fascicular block S1Q3T3 = right heart strain 2/2 pulmonary HTN and not PE

NSR with R axis deviation (Left posterior hemiblock) #42 NSR, HR 65 Left posterior fascicular block S1Q3T3 = right heart strain 2/2 pulmonary HTN and not PE S1Q3T3 NSR with R axis deviation (Left posterior hemiblock)

http://www.usfca.edu/fac-staff/ritter/Image74.gif

What is Your Clinical Diagnosis? #42 NSR, HR 65 Left posterior fascicular block S1Q3T3 = right heart strain 2/2 pulmonary HTN and not PE S1Q3T3 NSR with R axis deviation (Left posterior hemiblock)

S1Q3T3 ECG finding that indicates right heart strain Thus differential diagnosis should include PE and Pulmonary HTN (which this pt had) http://ems12lead.com/wp-content/uploads/sites/42/2010/11/S1Q3T3.jpg

65 y/o male on a new medication DIAGNOSIS? Digitalis Effect: Scooping t waves, U waves Digitalis toxicity: arrhythmias from PVCs to V fib, conduction abnormalities from first degree to third degree heart block http://www.jem-journal.com/article/S0736-4679(00)00312-7/fulltext

DIGITALIS EFFECT Scooping T waves U waves Digitalis toxicity: arrhythmias from PVCs to V fib, conduction abnormalities from first degree to third degree heart block Scooping T waves U waves http://www.jem-journal.com/article/S0736-4679(00)00312-7/fulltext

68 y/o female who collapses DIAGNOSIS? Monomorphic VT Sustained run = > 30 seconds http://sitemaker.umich.edu/ecgtutorial/ventricular_tachycardia

>30 second run = Sustained VT Monomorphic VT Monomorphic VT Sustained run = > 30 seconds >30 second run = Sustained VT http://sitemaker.umich.edu/ecgtutorial/ventricular_tachycardia

75 y/o male with COPD DIAGNOSIS? Multifocal atrial tachy -Originates from ectopic atrial foci, characterized by varying p-wave morphology and PR interval, irregular -Clinical correlations: COPD, advanced age, CHF, diabetes, theophylline use Tx: manage underlying disease, antiarrhythmics are ineffective http://www.emedu.org/ecg/searchdr.php?diag=SVT

Multifocal Atrial Tachycardia -Originates from ectopic atrial foci, characterized by varying p-wave morphology and PR interval, irregular -Clinical correlations: COPD, advanced age, CHF, diabetes, theophylline use Tx: manage underlying disease, antiarrhythmics are ineffective Irregular rhythm with varying P wave morphology & PR intervals http://www.emedu.org/ecg/searchdr.php?diag=SVT

60 y/o uremic patient DIAGNOSIS? Pericarditis: Diffuse ST elevations (concave upward), diffuse PR depressions, diffuse T wave inversions Causes: Uremia, viral/bacterial/fungal, Dressler syndrome, collagen vascular diseases, cancer, idiopathic 1. Diffuse concave up ST segment elevation. 2. T waves are concordant with ST segment. 3. ST segment depression in aVR and v1. 4. PR segment depression. 5. Absence of reciprocal ST segment depression. http://www.heartpearls.com/tag/ecg-in-pericarditis

Diffuse concave ST elevations Diffuse PR depressions Pericarditis Pericarditis: Diffuse ST elevations (concave upward), diffuse PR depressions, diffuse T wave inversions Causes: Uremia, viral/bacterial/fungal, Dressler syndrome, collagen vascular diseases, cancer, idiopathic 1. Diffuse concave up ST segment elevation. 2. T waves are concordant with ST segment. 3. ST segment depression in aVR and v1. 4. PR segment depression. 5. Absence of reciprocal ST segment depression. Diffuse concave ST elevations Diffuse PR depressions http://www.heartpearls.com/tag/ecg-in-pericarditis

53 y/o male with SOB and intermittent CP DIAGNOSIS? Electrical alternans—beat-to-beat alternation that’s relatively specific of pericardial effusion usually with cardiac tamponade, occurs because of the swinging motion of the heart within the effusion. http://en.wikipedia.org/wiki/Pericardial_effusion

Electrical Alternans Electrical alternans—beat-to-beat alternation that’s relatively specific of pericardial effusion usually with cardiac tamponade, occurs because of the swinging motion of the heart within the effusion. Beat-to-beat alternation is relatively specific of pericardial effusion usually with cardiac tamponade. http://en.wikipedia.org/wiki/Pericardial_effusion

55 y/o male with dizziness DIAGNOSIS? WPW: short PR, delta wave = delay in initial deflection of QRS -Occurs as preexcitation syndrome due to conduction from SA node to ventricle through accessory pathway that bypasses the AV node. http://pages.mrotte.com/wpw/

Wolff-Parkinson-White Delta wave, Short PR interval WPW: short PR, delta wave = delay in initial deflection of QRS -Occurs as preexcitation syndrome due to conduction from SA node to ventricle through accessory pathway that bypasses the AV node. Delta wave, Short PR interval Preexcitation syndrome through accessary pathway that bypasses AV node. http://pages.mrotte.com/wpw/

65 y/o dialysis patient DIAGNOSIS? http://www.emedu.org/ecg/volts.htm

Mild hyperkalemia: narrow, diffuse peaked T waves Severe hyperkalemia: PR prolongation, P wave flattens/disappears (junctional rhythm), QRS widens. *Complication: can progress to “sine wave” then asystole or V fib! http://www.emedu.org/ecg/crapsanyallans.php

30 y/o female on Furosemide Diagnosis? Hypokalemia: ST depression with U waves -Prominent U waves = marker for increased susceptibility to Torsades

Hypokalemia U waves (increased susceptibility for Torsades) Hypokalemia: ST depression with U waves -Prominent U waves = marker for increased susceptibility to Torsades U waves (increased susceptibility for Torsades) ST depressions also associated (not seen here)

50 y/o male with Nephrolithiasis Diagnosis? http://1.bp.blogspot.com/-ieVzYvG1LNM/UpXKeiy9dUI/AAAAAAAAA8Q/KpkJk2EV0Zk/s1600/ATC5.png

Hypercalcemia: Shortened QT Hypocalcemia: Prolonged QT Hypercalcemia: Short QT Hypocalcemia: Prolonged QT Hypercalcemia: Shortened QT Hypocalcemia: Prolonged QT http://www.angelfire.com/un/al6a/presentation/REsearch/electrolyte_and_metabolic_abnorm.htm

Hypothermia: “Osborn wave” (arrow) Amiodarone: prolonged QT 1) Hypothermia—”Osborn wave” (arrow) = convex hump at J point, due to altered ventricular action potential 2) Amiodarone—prolonged QT 3) TCA overdose—QRS/TQ prolongation with sinus tach 4) Intracranial bleed, esp SAH: “CVA T-wave pattern” = deep, wide T-wave inversions, also prolonged QT Hypothermia: “Osborn wave” (arrow) Amiodarone: prolonged QT TCA: QRS/QT prolongation with sinus tach Intracranial bleed: “CVA T-wave pattern” = deep, wide T wave inversions https://www.studyblue.com/notes/note/n/cardiology-ecg/deck/3113605

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: Clinician’s 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: Harrison’s 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/UserFiles/Servers/Ser ver_442934/Image/1.1/residentguides/final/icuguidebo ok.pdf. Accessed December 1, 2014.