1. ADVANCED ECGs
Beyond the basics…
Alastair Jones

2. Quiz Q1 55 year old man presents with central crushing chest pain.
Comment on the ECG and what is you treatment plan?

3. Quiz Q1

4. Quiz Q2
78 year old diabetic man. Previous MI. Presents with sudden onset SOB and an odd feeling in chest.
Comment on the ECG and what is you treatment plan?

5. Quiz Q2

6. Quiz Q3
45 year old male. Brought in by wife after an episode of severe indigestion last night. Now symptoms free. Insists he’s fine and wants to go home. Thinks his wife is worrying unnecessarily.
Obs fine. Bloods normal. Trop negative.
Comment on the ECG and what is your management plan?

7. Quiz Q3

8. Quiz Q4 78 year old lady who presents with ischaemic chest pain.
Comment on the ECG.
How can you confirm your diagnosis and what is your management plan?

9. Quiz Q4

10. Quiz Q5 20 year old student. Brought in after collapse.
Went to feel lightheaded and then blacked out for a few seconds.
Not happened before. Now feels fine and wants to go home.
Comment on his ECG and what would you tell him?

11. Quiz Q5

12. Quiz Q6
VT OR SVT?

13. Quiz Q6

14. Elevation in aVR

15. Elevation in aVR Single lead - significant?
Yes. STE in aVR implies lesion of the left main coronary artery

16. Elevation in aVR
STE in aVR itself of more than 1.5 mm carries a 75% specificity of LMCA and ~75% mortality!
STE in aVR + avL -- 90% specificity AMI
STE in aVR + V1 -- suggestive either prox LAD or LMCA occlusion but
STE in aVR > V1 -- more suggestive of LMCA
The significance of STE in aVR is dubious in the presence of BBB.

17. Sgarbossa Criteria Or how to detect AMI in LBBB
ST elevation ≥1 mm in a lead with upward (concordant) QRS complex - 5 points
ST depression ≥1 mm in lead V1, V2, or V3 (concordant) - 3 points
ST elevation ≥5 mm in a lead with downward (discordant) QRS complex - 2 points
≥3 points = specificity of 98% and sensitivity of 20% (10 paper meta-analysis of 614 patients)

18. Sgarbossa Criteria

19. Sgarbossa Criteria
Only one lead required BUT the significance of elevation in aVR is no longer certain.
Serial / old ECG’s can also help

20. Wellens’ Syndrome
Wellens’ syndrome is a pattern of inverted or biphasic T waves in V2-3 (in patients presenting with ischaemic chest pain) that is highly specific for critical stenosis of the left anterior descending artery.
Patients may be pain free by the time the ECG is taken and have normally or minimally elevated cardiac enzymes; however, they are at extremely high risk for extensive anterior wall MI within the next 2-3 weeks.
Type 1 Wellens’ T-waves are deeply and symmetrically inverted
Type 2 Wellens’ T-waves are biphasic, with the initial deflection positive and the terminal deflection negative

21. Wellens’ Syndrome - Type 1

22. Wellens’ Syndrome - Type 2

23. Wellen’s Syndrome
 Wellen's criteria is not dependent on ST changes, just the T inversion!
VERY worrying...Signifies critical LAD stenosis!
100% of 180 patients with the pattern having >50% stenosis of the left anterior descending coronary artery (mean = 85%), with complete or near complete occlusion in almost 60%.
Likely to need a cath lab rather than medical therapy...
Should be investigated urgently even if now asymptomatic!
BUT - young children and especially female up to 40 years, may have normal variant of T inversion (the juvenile pattern).

24. Posterior MI

25. Posterior MI Be wary in any patient with infero-lateral ischaemia.
Posterior MI is suggested by the following changes in V1-3:
Horizontal ST depression
Tall, broad R waves (>30ms)
Upright T waves
Dominant R wave (R/S ratio > 1) in V2

26. Posterior MI Posterior Leads:
V7 – Left posterior axillary line, in the same horizontal plane as V6.
V8 – Tip of the left scapula, in the same horizontal plane as V6.
V9 – Left paraspinal region, in the same horizontal plane as V6.

27. Posterior MI

28. Posterior MI
The degree of ST elevation seen in V7-9 is typically modest – note that only 0.5 mm of ST elevation is required to make the diagnosis of posterior MI!

29. Posterior MI

30. Posterior MI

31. Brugada Syndrome
25 year old Asian male has had a collapse. Now feels fine and wants to go home...

32. Brugada Syndrome
Brugada syndrome is an ECG abnormality with a high incidence of sudden cardiac death in structurally normal hearts...
Sodium channel mutation (at least 60 different types described so far)
Diagnosis depends upon ECG criteria (which may be transient and clinical criteria (VF, VT, syncope, FHx sudden cardiac death <45)
Definitive treatment = ICD

33. Brugada Syndrome May be unmasked / augmented by the following: Fever
Ischaemia
Multiple Drugs: Sodium channel blockers (eg Flecainide, Propafenone), Calcium channel blockers, Alpha agonists, Beta Blockers, Nitrates, Cholinergic stimulation, Cocaine, Alcohol
Hypokalaemia
Hypothermia
Post DC cardioversion

34. Brugada Syndrome - Type 1
Type 1: Coved ST segment elevation >2mm in >1 of V1-V3 followed by a negative T wave (don’t confuse with RBBB which should have ST depression)

35. Brugada Syndrome - Type 2
Type 2 has >2mm of saddleback shaped ST elevation.

36. Brugada Syndrome - Type 3
Brugada type 3 can have either type 1 or type 2 morphology, but with <2mm of ST segment elevation.

37. Brugada Syndrome Do they need admitting?
Type 1 ECG and symptomatic = YES!
If undiagnosed - 10% mortality per year...
Asymptomatic patients with a type 1 ECG pattern and all type ECG patterns can probably go home and have outpatient electrophysiology...

38. Brugada Syndrome
...however, EPS is far from a gold standard, with a negative predictive value of less than 50% and some studies suggest that we might be getting a little over-excited about this relatively recently described ECG finding (1992).
One study followed 98 asymptomatic japanese patients with a type 1 ECG found incidentally for 7.8 years and found them to have no greater mortality than the rest of a strong cohort.  This highlights the importance of the clinical criteria required for diagnosis listed above.

39. Trifasicular block
Disease in all 3 conduction fasicles (RBB, LAF, LPF)
May be complete or incomplete:
Incomplete (or Impending) – RBBB, LAD, 1st degree HB
Complete – 3rd degree HB and bifasicular block (usually RBBB and LAD)

40. Trifasicular block (incomplete)

41. Trifasicular block
Incomplete trifascicular block may progress to complete heart block.
Patients who present with a syncopal episode and have an ECG showing incomplete trifascicular block should be admitted for a cardiology review as they may be having episodes of complete heart block. Therefore, some of these patients will require a pacemaker.

42. VT or SVT with aberrant conduction???

43. VT or SVT with aberrant conduction???
3 possibilities: VT
SVT with aberrant conduction due to bundle branch block
SVT with aberrant conduction due to the Wolff-Parkinson-White syndrome

44. VT or SVT with aberrant conduction???
While it is not always possible to differentiate VT from SVT with aberrant conduction it is important to try. SVT is amenable to AV nodal blockers. But someone in VT can suffer haemodynamic collapse if AV blockers given...
Unfortunately, the electrocardiographic differentiation of VT from SVT with aberrancy is not always possible. However, there are several electrocardiographic features that increase the likelihood of VT:

45. More likely to be VT... Absence of typical RBBB or LBBB morphology
Extreme axis deviation (“northwest axis”)
Very broad complexes (>160ms)
AV dissociation (P and QRS complexes at different rates)

46. More likely to be VT...
Capture beats — occur when the sinoatrial node transiently ‘captures’ the ventricles, in the midst of AV dissociation, to produce a QRS complex of normal duration.
Fusion beats — occur when a sinus and ventricular beat coincides to produce a hybrid complex.

47. More likely to be VT...
Brugada’s sign –  The distance from the onset of the QRS complex to the nadir of the S-wave is > 100ms
Josephson’s sign – Notching near the nadir of the S-wave

48. More likely to be VT...
Positive or negative concordance throughout the chest leads, i.e. leads V1-6 show entirely positive (R) or entirely negative (QS) complexes, with no RS complexes seen.
RSR’ complexes with a taller left rabbit ear. This is the most specific finding in favour of VT. This is in contrast to RBBB, where the right rabbit ear is taller. VT
RBBB

49. The likelihood of VT is also increased if:
Age > 35 (positive predictive value of 85%)
Structural heart disease
Ischaemic heart disease
Previous MI
Congestive heart failure
Cardiomyopathy
Family history of sudden cardiac death (suggesting conditions such as HOCM, congenital long QT syndrome, Brugada syndrome or arrhythmogenic right ventricular dysplasia that are associated with episodes of VT)

50. The likelihood of SVT with aberrancy is increased if:
Previous ECGs show a bundle branch block pattern with identical morphology to the broad complex tachycardia.
Previous ECGs show evidence of WPW (short PR < 120ms, broad QRS, delta wave).
The patient has a history of paroxysmal tachycardias that have been successfully terminated with adenosine or vagal manoeuvres.
HOWEVER - IF IN DOUBT TREAT AS VT

51. Quiz Answers Q1
55 year old man presents with central crushing chest pain.
Comment on the ECG and what is you treatment plan?

52. Quiz Answers Q1

53. Quiz Answers Q1 NSR Widespread ST depression
Elevation in aVR --> LMCA lesion!!
D/W Papworth for ?PPCI, ACS Rx etc…

54. Quiz Answers Q2
78 year old diabetic man. Previous MI. Presents with sudden onset SOB and an odd feeling in chest.
Comment on the ECG and what is you treatment plan?

55. Quiz Answers Q2

56. Quiz Answers Q2 Paced rhythm - Broad complexes
Positive Scarbossa Criteria
> 5mm ST elevation in III, aVF
< 1mm ST depression V2, V3
1mm ST elevation aVL
Needs PPCI

57. Quiz Answers Q3
45 year old male. Brought in by wife after an episode of severe indigestion last night. Now symptoms free. Insists he’s fine and wants to go home. Thinks his wife is worrying unnecessarily.
Obs fine. Bloods normal. Trop 12.
Comment on the ECG and what is your management plan?

58. Quiz Answers Q3

59. Quiz Answers Q3 Wellens’ type 1 - deep symmetrical TWI anteriorly.
Likely has a severe LAD stenosis and should be investigated urgently.
Refer medics for urgent angiography.

60. Quiz Answers Q4
78 year old lady who presents with ischaemic chest pain.
Comment on the ECG.
How can you confirm your diagnosis and what is your management plan?

61. Quiz Answers Q4

62. Quiz Answers Q4 Likely posterior MI (borderline inferior MI also)
Anterior ST depression with a dominant R wave.
Confirm with posterior leads
Treat as per AMI - PPCI

63. Quiz Answers Q5 20 year old student. Brought in after collapse.
Went to feel lightheaded and then blacked out for a few seconds.
Not happened before. Now feels fine and wants to go home.
Comment on his ECG and what would you tell him?

64. Quiz Answers Q5

65. Quiz Answers Q5 Brugada syndrome type 1
Risk of sudden death. Need admission for an ICD...

66. Quiz Answers Q6
VT OR SVT?

67. Quiz Answers Q6

68. Quiz Answers Q6
Probably SVT with aberrant conduction.