1. ECG Underwriting Puzzler Presented by: Bill Rooney, M.D.

2. Obtaining Best Results from this presentation Select “From the beginning” 2 For best results—please do the following: Select “Slide Show” from the menu option on top For best results—please do the following: Select “Slide Show” from the menu option on top Slowly click through the presentation Have fun!---Good luck Slowly click through the presentation Have fun!---Good luck

3. ECG Puzzler 3 QUESTION???? How would you interpret this ECG? QUESTION???? How would you interpret this ECG?

4. 4 If you said It looks normal other than for one PVC you were correct. PVC’s can exist in many forms and configurations. Always be on the lookout!! I will take you down the road of PVC’s and the mischief they can cause. If you said It looks normal other than for one PVC you were correct. PVC’s can exist in many forms and configurations. Always be on the lookout!! I will take you down the road of PVC’s and the mischief they can cause.

5. ECG Puzzler 5 The PVC can be seen in several leads below. It is the same PVC but seen from different angles. PVC’s are early occurring beats with a wide (typically >0.16 sec) QRS complex.

6. ECG Puzzler 6 PVC’s have a QRS morphology that is different than the sinus QRS complexes. PVC’s typically have marked repolarization abnormalities. If several PVC’s are present and they all have the same QRS morphology they are called unifocal PVC’s. But, if those PVC’s have different QRS morphologies then they are referred to as multifocal PVC’s. When a PVC alternates with a normal sinus beat this is called ventricular bigeminy. A PVC every third beat is ventricular trigeminy. When a PVC alternates with a normal sinus beat this is called ventricular bigeminy. A PVC every third beat is ventricular trigeminy. 2 PVC’s in a row are called a ventricular couplet. 3 PVC’s in a row are called a ventricular triplet but 3 or more PVC’s in a row are also called ventricular tachycardia.

7. The Many Faces of PVC’s 7 Multifocal PVC V-tach Single PVC Triplet PVC’s Couplet Bigeminy

8. One more ECG to consider 8 QUESTION???? How would you interpret this ECG? QUESTION???? How would you interpret this ECG?

9. What is that strange beat??? 9 Is that artifact in leads I, II, and III or is it an abnormality? Answer: The wide and bizarre beat, which is seen in multiple leads, is a PVC. Answer: The wide and bizarre beat, which is seen in multiple leads, is a PVC. Other than the PVC the ECG looks to be WNL.

10. ECG Puzzler 10 Here is a rhythm strip from the previous slide This is called a “compensatory pause”. The pause allows the ventricles to reset and be ready for the next impulse coming down from the SA node. Interpolated PVC’s are rare. The PVC is “sandwiched” in between 2 normal beats and there is no pause. If the ventricle however is ready for the impulse then the next normal QRS complex occurs as scheduled and causes the PVC to become interpolated”. Single PVC The SA node continues to fire but the beat is not conducted as the ventricle is just not ready for it yet. The p wave gets buried in the QRS complex somewhere. Notice the pause after the PVC?

11. 11 That concludes this issue of the ECG Puzzler!! Contact me if you have any questions!! PVC’s For further reading: Please see page 137 in Dale Dubin’s 6 th edition of Rapid Interpretation of EKG’s For further reading: Please see page 137 in Dale Dubin’s 6 th edition of Rapid Interpretation of EKG’s There are no additional mortality concerns with interpolated PVC’s versus PVC’s with the compensatory pause but it remains important to be able to recognize them. ECG Solved