ECG Practice Cases: Part 1 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/

77 y/o male with BP 170/95 DIAGNOSIS? #8 NSR HR 95 LVH with repolarization abnormality -LVH strain ST depression and T-wave inversion in anterolateral leads (I, aVL, V5, or V6) Cannot rule out septal infarct

What Can Cause This ECG Change? #8 NSR HR 95 LVH with repolarization abnormality -LVH strain ST depression and T-wave inversion in anterolateral leads (I, aVL, V5, or V6) Cannot rule out septal infarct R in aVL > 11mm R in V5/V6 + S in V1/V2 > 35mm R in I + S in III > 25 mm R in aVF > 20mm S in aVR > 14mm Ortiz: Lead I: R > 14 Lead aVL: R > 12 S in V1 + R in V5/V6 > 35 NSR with LVH & repolarization abnormality (R in I > 14, R in aVL > 12, S in V2 + R in V5 > 35) *LVH strain shown as ST depression and T wave inversion in anterolateral leads (I, aVL, V5 or V6)

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_microscopic_pathology http://www.crc-erlangen.de/methods/index.html

54 y/o female admitted for stroke DIAGNOSIS? #11 NSR, HR 70 Rightward axis Left atrial enlargement Septal infarct, age undetermined

What Can Cause LAE? NSR with R axis deviation (down in I) #11 NSR, HR 70 Rightward axis (down in I) Left atrial enlargement Diphasic p with downward terminal phase > 1mm wide and 1mm deep in V1. M-shaped P in I, II, or aVL P > 120ms (3 small boxes) Septal infarct, age undetermined NSR with R axis deviation (down in I) Left atrial enlargement (p > 120ms, M-shaped in II) Old septal infarct (Q waves in V1 & V2) Low Voltage

Left Atrial Enlargement Etiology Mitral stenosis Mitral regurgitation LVH Atrial fibrillation http://ecg.utah.edu/lesson/7 https://www.youtube.com/watch?v=gGz0T_dw0Ho

80 y/o female with DOE DIAGNOSIS? #12 NSR, HR 90 RBBB Left anterior fascicular block Possible anterolateral infarct

NSR with RBBB & Left anterior fascicular block #12 NSR, HR 90 RBBB Left anterior fascicular block Possible anterolateral infarct RBBB clinical correlations: Pulm HTN, ASD, ischemia, sudden onset PE, acute exacerbation of COPD NSR with RBBB & Left anterior fascicular block (left axis deviation—down in II, up in I)

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What Can Cause RBBB? NSR with RBBB & Left anterior fascicular block #12 NSR, HR 90 RBBB Left anterior fascicular block Possible anterolateral infarct RBBB clinical correlations: Pulm HTN, ASD, ischemia, sudden onset PE, acute exacerbation of COPD NSR with RBBB & Left anterior fascicular block (left axis deviation—down in II, up in I) (RSR’ in V1, broad S in V6)

Right Bundle Branch Block Etiology Pulmonary HTN ASD Ischemia PE Acute exacerbation of COPD http://research.vet.upenn.edu/smallanimalcardiology/ECGTutorial/AbnormalECGs/tabid/4960/Default.aspx http://en.wikipedia.org/wiki/Right_bundle_branch_block

96 y/o female with new chest pain DIAGNOSIS? #24 NSR, HR 98 Septal STEMI (anterolateral?) Possible left atrial enlargement

DIAGNOSIS? NSR with Anterior STEMI LVH (S in V2 + R in V6 >35) #24 NSR, HR 98 Anterior STEMI Possible left atrial enlargement (wide P in II, diphasic P in V1) NSR with Anterior STEMI (ST elevations in V2-V4, Reciprocal ST depressions in II, III, aVF) LVH (S in V2 + R in V6 >35) LAE (P > 3 small boxes, diphasic in V1)

Location Leads Occluded Vessel Anterior V2-V4 LAD Anteroseptal V1-V4 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_245a975b-66ad-4f7e-86d8-82d3ca7d0120.jpg

Reciprocal Changes in MI ***Normal R-wave progression from V1-V6 occurs with a reciprocal decrease in S and “biphasic” (R = S) in V3 or V4. *In anterior MI, loss of R wave progression (instead of Q waves) with biphasic QRS occurring more laterally in V4-V6. Loss of R wave progression http://www.emedu.org/ecg/crapsanyallans.php

Right Ventricular Infarction http://www.emedu.org/ecg/crapsanyallans.php http://www.ems12lead.com/2008/10/17/12-lead-ecg-lead-placement-diagrams/

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 I, aVL, possibly anterior leads Posterior Abnormally tall R & T waves in V1-V3 V1-V3 Subendocardial No abnormal Q waves

DDX for ST segment elevations Ischemia Acute MI Prinzmetal’s 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 LVH/LBBB ST elevations usually localized to V1-V3

79 y/o female with CAD DIAGNOSIS? #9 NSR, HR 70 LBBB

(deep S in V1, inverted T in V6) What can Cause LBBB? #9 NSR, HR 70 LBBB Clinical correlations: heart disease (HTN, valvular, ischemic), severe AS NSR with LBBB (deep S in V1, inverted T in V6)

Left Bundle Branch Block Etiology HTN Ischemia Valvular heart disease Severe aortic stenosis http://research.vet.upenn.edu/smallanimalcardiology/ECGTutorial/AbnormalECGs/tabid/4960/Default.aspx http://en.wikipedia.org/wiki/Left_bundle_branch_block

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.