1. Dr Kiran Veera Ed physician and co-demt Bendigo health
Pattern recognition
Dr Kiran Veera
Ed physician and co-demt
Bendigo health

2. Rate
Rhythm
Axis
Intervals
Chamber enlargements
Ischaemia

4. 75yo male with HTN, DM-2 complains of angina
What does this ECG show?

5. Not always LMCA obstruction
Not always LMCA obstruction. There are 10 other causes of STE in aVR – important to think of differential

6. LMCA Obstruction
STE in aVR ddx: PE, LVH with strain, LBBB(including PPM), SVTs, hypok+, aortic dissection, Na ch pathology (TCA, Brugada etc), severe anaemia.
Hyper K+ can also do it – causes Rightward axis (therefore positive aVR). Ischaemia rarely causes rightward axis.

10. LMCA Obstruction Widespread horizontal ST depression
ST elevation in aVR ≥ 1mm
ST elevation in aVR ≥ V1

11. Also seen in
Prox LAD obstruction
Severe Triple vessel disease
Diffuse subendocardial ischaemia
PE, LVH with strain, LBBB(including PPM), SVTs, hypok+, aortic dissection, Na ch pathology (TCA, Brugada etc), severe anaemia

12. In the presence of anginal symptoms,
STE in aVR + STE in V1
- Highly predictive of LMCA or Prox LAD obstruction
STE in aVR > STE in V1
- almost always indicates a LMCA obstruction (81% sensitive and 80% specific)

13. ST elevation in aVR and V1 of similar magnitude.
Widespread ST depression (V3-6, I, II, III, aVF)
Patient had a severe ostial LAD thrombus that was close to the left main. 

14. Another classic example of the LMCA / 3VD ECG pattern

15. I would treat a patient with LMCA obstruction with all the following except:
Aspirin
Clopidogrel
Heparin
Early Cath lab

16. 40yo female with anxiety, palpitations and pseudoseizures

18. Brugada Syndrome

19. RBBB-like pattern with secondary R’ wave following the QRS complex.
Could be a cause of SIDS / SUDI
RBBB-like pattern with secondary R’ wave following the QRS complex.
ST elevation at the J point > 2mm with a “coved”
T wave inversion

22. Only proven therapy is ICD
Diagnosis
ECG plus one of the following:
Documented VF or VT
Family history of SCD at <45 years old
Coved-type ECGs in family members
Syncope
Nocturnal agonal respiration
Only proven therapy is ICD

23. Take Home points
Consider Brugada syndrome in any patient presenting after syncope
ECG: (I)RBBB + STE in V1 - V2
Coved STE is most concerning
Discuss/ refer to electrophysiologist

24. 50yo male with syncope

26. Trifascicular block

27. But AVN is not a fascicle - why is it a trifascicular block?