The Company You Keep ® 1 EKG Refresher for Interpreters Liz Collier, FLMI, FALU, CLU AVP Underwriting QA, Research & Training April 4, 2011 Liz Collier, FLMI, FALU, CLU AVP Underwriting QA, Research & Training April 4, 2011

Antitrust New York Life adheres to the letter and spirit of the antitrust laws. The information in this presentation is intended to advance the knowledge and improve the risk assessment skills of the participants. Under no circumstances shall this presentation be used as a forum for the pricing of specific products, determining how they are marketed, or for any other anticompetitive purpose. Copyright 2010 New York Life Insurance Company. All rights reserved. New York Life adheres to the letter and spirit of the antitrust laws. The information in this presentation is intended to advance the knowledge and improve the risk assessment skills of the participants. Under no circumstances shall this presentation be used as a forum for the pricing of specific products, determining how they are marketed, or for any other anticompetitive purpose. Copyright 2010 New York Life Insurance Company. All rights reserved. 2

3 OVERVIEW EKG Leads Axis Check List Case Studies Mind the PQRSTs Questions EKG Leads Axis Check List Case Studies Mind the PQRSTs Questions

EKG Lead Placement Limb Leads 4

EKG Lead Placement Chest Leads 5

EKG Leads 6

7 Axis

Check List 12 leads, STD mark, paper speed Heart rate (NSR?) Heart rhythm (arrhythmias?) QRS axis PR interval QRS interval P waves Q waves ST waves T waves QT interval R wave progression 12 leads, STD mark, paper speed Heart rate (NSR?) Heart rhythm (arrhythmias?) QRS axis PR interval QRS interval P waves Q waves ST waves T waves QT interval R wave progression 8

Case Study #1 59-year old male NS $4,000, /81 Exam –HTN on one anti-hypertensive med for last 2 years –Examiner heard a grade IV / VI systolic ejection murmur throughout precordium, aortic location, radiates to carotids 59-year old male NS $4,000, /81 Exam –HTN on one anti-hypertensive med for last 2 years –Examiner heard a grade IV / VI systolic ejection murmur throughout precordium, aortic location, radiates to carotids 9

Case Study #2 56-year old male NS $500, /74 Exam: no medical history APS: last visit 2003, no EKG in APS 56-year old male NS $500, /74 Exam: no medical history APS: last visit 2003, no EKG in APS 10

Case Study #3 46-year old female NS $1,000, /68 Exam: no medical history APS: no significant history, runs marathons, 1999 EKG looks similar 46-year old female NS $1,000, /68 Exam: no medical history APS: no significant history, runs marathons, 1999 EKG looks similar 11

Case Study #4 64-year old female NS $5,000, /76 Exam: no medical history APS: 2009 EKG had non-specific ST-T wave changes, only saw MD one time for a physical 64-year old female NS $5,000, /76 Exam: no medical history APS: 2009 EKG had non-specific ST-T wave changes, only saw MD one time for a physical 12

Case Study #5 54-year old male NS $1,000, /83 Exam: physical in 2009, on anti-hypertensive med Daughter’s EKG looks similar 54-year old male NS $1,000, /83 Exam: physical in 2009, on anti-hypertensive med Daughter’s EKG looks similar 13

Case Study #6 59-year old male Smoker $1,000, /81 Exam: back surgery in 1984 Current APS requested: no records found 59-year old male Smoker $1,000, /81 Exam: back surgery in 1984 Current APS requested: no records found 14

Case Study #7 28-year old female NS $1,000, /60 Exam: 2009 CT needed due to syncopal episode- results normal APS: II / VI systolic ejection murmur at left sternal border, consistent with VSD, echo showed very small VSD 28-year old female NS $1,000, /60 Exam: 2009 CT needed due to syncopal episode- results normal APS: II / VI systolic ejection murmur at left sternal border, consistent with VSD, echo showed very small VSD 15

Case Study #8 59-year old female NS $600, /83 Exam: no medical history, physical last year APS: 2009 echo- 1+ MR, TR, AR 59-year old female NS $600, /83 Exam: no medical history, physical last year APS: 2009 echo- 1+ MR, TR, AR 16

Mind the PQRSTs AF- P waves absent, rate irregularly irregular and indeterminate IRBBB sec, RSR’ in V1/ V2 LAFB sec, LAD, Q(I), S(III), S>R(III/III/F) LBBB- LAD, complete RR’ in V5-V6/I/L, ST depr, T inversion Q- significant- 1mm wide x 1/3 QRS ht deep QT estimate- measure beginning of Q to end of T, should be < ½ RR for heart rate of bpm T wave major- full inversion, depth 1mm or ^ T wave minor- low, flat or inverted < 1mm AF- P waves absent, rate irregularly irregular and indeterminate IRBBB sec, RSR’ in V1/ V2 LAFB sec, LAD, Q(I), S(III), S>R(III/III/F) LBBB- LAD, complete RR’ in V5-V6/I/L, ST depr, T inversion Q- significant- 1mm wide x 1/3 QRS ht deep QT estimate- measure beginning of Q to end of T, should be < ½ RR for heart rate of bpm T wave major- full inversion, depth 1mm or ^ T wave minor- low, flat or inverted < 1mm 17

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