1. Upper Level Conference UNC Internal Medicine 10/21/09
Advanced EKG patterns
Upper Level Conference
UNC Internal Medicine
10/21/09

2. Basics
Always examine an EKG systematically then come up with your interpretation

3. What is the abnormality?
LVH
What are the criteria for LVH?
Sokolow-Lyon: V2S + V5R >= 35
Cornell: avLR + V3S > 24 in men, > 20 in women
Other: avL > 11

4. What is the differential diagnosis for that axis?
What is the axis?
What is the differential diagnosis for that axis?
Left Anterior Fascicular Block
1. Criteria for LAFB?
LAD: LVH, inferior MI, LAFB, LBBB
RAD: RVH, pul HTN/PE/COPD, LPFB, lateral MI
LAFB: rS in avF, qR in I

6. Describe this rhythm using your “tachycardia” algorithm:
What rhythm is this? How do you know?
Regular, wide complex tachycardia

7. Any regular wide complex tachydardia:
Brugada Criteria – helps you discern between VT and SVT with aberrancy
If ANY of the criteria are satisfied, its VT
If NO criteria is satisfied, its SVT with aberrancy

8. Brugada criteria Concordance in precordial leads
R to S interval > 100ms in a precordial lead
AV dissociation?
Morphology look like VT?
Concordance specifically defined as NO RS complexes in all precordial leads
R to S interval specifically definied as beginning of R to deepest part of S
AV dissociation specifically definied as “capture beat” or “fusion beat”
For EP expert

9. Concordance (lack of RS complex in precordial leads)

10. Note capture beat

11. What are the abnormalities?
What is the syndrome?
Brugada syndrome – Inherited Na channel abnormality, can lead to sudden death
Coved ST segment elevation in anterior precordial leads + TWI
AICD if syncope or inducible VT on EP study

12. In summary Formal diagnosis of LVH LAFB and LPFB
Approach to tachycardia
Distinguish between VT and SVT with aberrancy – Brugada criteria
Brugada syndrome