1. Some Interesting EKGs Justin Fox, MD Fellow in Cardiovascular Disease Northwestern Memorial Hospital Thank You: EKG Maven, http://ecg.bidmc.harvard.edu/maven/mavenmain.asp

2. Asymptomatic 26yo …. Normal EKG (with possible T wave abnormality in III)

3. Method of EKG Interpretation Rate (300, 150, 100, 75, 60, 50) Rhythm (Is it NSR?) Axis (Normal -30 to +90) Intervals Chamber enlargement/hypertrophy q waves, ST segments, R wave progression, T waves, etc Pattern Recognition

4. Another asymptomatic 26yo… Ectopic atrial rhythm – look at p wave axis before deciding on sinus rhythm. A sinus P wave should be upright in inferior leads, and negative in aVR

5. 47yo M w/ Chest Pain http://library.med.utah.edu/kw/ecg/mml/ecg_12lead028.html Anterior ST elevations, Tombstoning, reciprocal depressions inferiorly. Acute AWMI

6. Another 47yo M w/ Chest Pain Pericarditis, diffuse ST elevation, PR elevation aVR

7. 47yo M w/ chest pain (R sided V1- V6) IWMI w/ posterior and RV involvement (STE in V4R), likely RCA infarct (STE in III greater than II suggests RCA more likely than LCx)

8. 75yo M w/ Chest Pain http://www.sbhemresidency.com/html/2004-05_ekg_quizzes.html Diffuse ST depressions with ST elevation in aVR. This suggests global ischemia – i.e. 3v dz or L main disease

9. 32yo asymptomatic man Wolff-Parkinson-White Syndrome

10. What Could Happen to That Guy AF w/ RVR/WPW @234, Treat w/ Procainamide, which slows conduction thru bypass tract. (This EKG is on the internal medicine boards)

11. Another interesting 32yo M Brugada Syndrome – RBBB type pattern with ST elevations V1-2. Sodium channelopathy, associated with sudden death.

12. What Might Happen to This Guy

13. 69yo F w/ Dyspnea and Clear CXR Sinus Tachycardia w/ S1Q3T3 pattern suggestive of PE

14. What’s the rhythm? Sinus rhythm w/ motion artifact due to Parkinson’s Disease. Note “flutter waves” only seen in leads that use R arm lead (and V1). Pt’s tremor is worse on right.

15. What’s the Rhythm? Left leg tremor 2/2 CVVHD artifact (vascath in L femoral vein). “Flutter” went away when CVVH machine was paused. Also low voltage QRS.

16. 74yo F….. http://library.med.utah.edu/kw/ecg/mml/ecg_12lead016.html RBBB with a L axis due to L anterior fascicular block (qR in I and aVL, rS in III). This is bifascicular block

17. How is this one different? www.ecglibrary.com/ecgs/trifas2.gif Same as prior but now w/ PR prolongation. This is “trifascicular block” – either left posterior fascicle is slow or AV node disease

18. What’s Wrong With This Patient’s Dual Chamber Pacemaker? http://sprojects.mmi.mcgill.ca/heart/comments/exe000207r3.html V-paced w/ RBBB pattern. PPM perforated septum, pacing now coming from LV cavity. (This is also seen with a normally functioning BiV pacer).

19. 80yo M w/ longstanding AFib AF w/ CHB and Junctional escape, Dig toxicity

20. What’s This? Bidirectional VT, Dig toxicity

21. Huh? Ghany R and de Marchena E. N Engl J Med 2007;356:e6 2 hearts – heterotopic heart transplant with native heart left in position.

23. Some Extras….

24. And another asymptomatic 26yo… Limb lead reversal (neg p and neg QRS in I), aVL looks like aVR should, also sinus arrhythmia

25. http://library.med.utah.edu/kw/ecg/ecg_outline/Lesson6/index.html #1=AV Wenckebach (4:3, then 3:2); #2=SA Wenckeach (4:3); #3=Pacemaker Wenckebach http://www.cardiosource.com/casestudies/casestudy.asp?TabID=4372&studyID=493 Rhythm Strips From 3 Different Patients

26. Patel A and Getsos J. N Engl J Med 1994;330:680 What’s The Rhythm?

27. Saadlla H. N Engl J Med 2004;351:e4 A better look at Osborn Waves

28. What’s the Lab Abnormality? Hyperkalemia