1. ECG Practice Cases: Part 1
Megan Chan, PGY-1
UHCMC 2015
Torsades picture:

2. 77 y/o male with BP 170/95 DIAGNOSIS? #8 NSR HR 95
LVH with repolarization abnormality
-LVH strain ST depression and T-wave inversion in anterolateral leads (I, aVL, V5, or V6)
Cannot rule out septal infarct

3. What Can Cause This ECG Change?#8
NSR HR 95
LVH with repolarization abnormality
-LVH strain ST depression and T-wave inversion in anterolateral leads (I, aVL, V5, or V6)
Cannot rule out septal infarct
R in aVL > 11mm
R in V5/V6 + S in V1/V2 > 35mm
R in I + S in III > 25 mm
R in aVF > 20mm
S in aVR > 14mm
Ortiz:
Lead I: R > 14
Lead aVL: R > 12
S in V1 + R in V5/V6 > 35
NSR with LVH & repolarization abnormality
(R in I > 14, R in aVL > 12, S in V2 + R in V5 > 35)
*LVH strain shown as ST depression and T wave inversion in anterolateral leads (I, aVL, V5 or V6)

4. Left Ventricular Hypertrophy
Etiology:
Chronic HTN
Aortic stenosis
Aortic insufficiency
Long-standing CAD
Some forms of congenital heart disease

5. 54 y/o female admitted for stroke
DIAGNOSIS?
#11
NSR, HR 70
Rightward axis
Left atrial enlargement
Septal infarct, age undetermined

6. What Can Cause LAE? NSR with R axis deviation (down in I)
#11
NSR, HR 70
Rightward axis (down in I)
Left atrial enlargement
Diphasic p with downward terminal phase > 1mm wide and 1mm deep in V1.
M-shaped P in I, II, or aVL
P > 120ms (3 small boxes)
Septal infarct, age undetermined
NSR with R axis deviation (down in I)
Left atrial enlargement (p > 120ms, M-shaped in II)
Old septal infarct (Q waves in V1 & V2)
Low Voltage

7. Left Atrial Enlargement
Etiology
Mitral stenosis
Mitral regurgitation
LVH
Atrial fibrillation

8. 80 y/o female with DOE DIAGNOSIS? #12 NSR, HR 90 RBBB
Left anterior fascicular block
Possible anterolateral infarct

9. NSR with RBBB & Left anterior fascicular block
#12
NSR, HR 90
RBBB
Left anterior fascicular block
Possible anterolateral infarct
RBBB clinical correlations: Pulm HTN, ASD, ischemia, sudden onset PE, acute exacerbation of COPD
NSR with RBBB & Left anterior fascicular block
(left axis deviation—down in II, up in I)

11. What Can Cause RBBB? NSR with RBBB & Left anterior fascicular block
#12
NSR, HR 90
RBBB
Left anterior fascicular block
Possible anterolateral infarct
RBBB clinical correlations: Pulm HTN, ASD, ischemia, sudden onset PE, acute exacerbation of COPD
NSR with RBBB & Left anterior fascicular block
(left axis deviation—down in II, up in I)
(RSR’ in V1, broad S in V6)

12. Right Bundle Branch Block
Etiology
Pulmonary HTN
ASD
Ischemia PE
Acute exacerbation of COPD

13. 96 y/o female with new chest pain
DIAGNOSIS?
#24
NSR, HR 98
Septal STEMI (anterolateral?)
Possible left atrial enlargement

14. DIAGNOSIS? NSR with Anterior STEMI LVH (S in V2 + R in V6 >35)
#24
NSR, HR 98
Anterior STEMI
Possible left atrial enlargement (wide P in II, diphasic P in V1)
NSR with Anterior STEMI
(ST elevations in V2-V4, Reciprocal ST depressions in II, III, aVF)
LVH (S in V2 + R in V6 >35)
LAE (P > 3 small boxes, diphasic in V1)

15. Location Leads Occluded Vessel
Anterior
V2-V4
LAD
Anteroseptal
V1-V4
Anterolateral
V1-V6, I, aVL
LAD, diagonal
Lateral
V5-V6, I, aVL
Circumflex, diagonal
Inferior
II, III, aVF
RCA, circumflex
Posterior
Tall R in V1-V3,
ST depression in V1-V2
RCA

16. Reciprocal Changes in MI
***Normal R-wave progression from V1-V6 occurs with a reciprocal decrease in S and “biphasic” (R = S) in V3 or V4.
*In anterior MI, loss of R wave progression (instead of Q waves) with biphasic QRS occurring more laterally in V4-V6.
Loss of R wave progression

17. Right Ventricular Infarction

18. Summary of ECG Changes in MI
Location of MI
Presence of Q wave or ST elevation
Reciprocal ST depression
Anterior
V1-V6 + loss of R wave progression
II, III, aVF
Lateral
I, aVL, V5, V6
V1, V3
Inferior
I, aVL, possibly anterior leads
Posterior
Abnormally tall R & T waves in V1-V3
V1-V3
Subendocardial
No abnormal Q waves

19. DDX for ST segment elevations
Ischemia
Acute MI
Prinzmetal’s angina
Post MI (ventricular aneurysm)
Acute pericarditis
LVH/LBBB
Rarer Causes:
Class 1C antiarrhythmic drugs
Hypercalcemia
Hyperkalemia
Hypothermia
Brugada pattern
DC cardioversion
Myocardial injury
Myocarditis
LV tumor
Trauma to ventricles
LVH/LBBB ST elevations usually localized to V1-V3

20. 79 y/o female with CAD
DIAGNOSIS? #9
NSR, HR 70
LBBB

21. (deep S in V1, inverted T in V6)
What can Cause LBBB? #9
NSR, HR 70
LBBB
Clinical correlations: heart disease (HTN, valvular, ischemic), severe AS
NSR with LBBB
(deep S in V1, inverted T in V6)

22. Left Bundle Branch Block
Etiology
HTN
Ischemia
Valvular heart disease
Severe aortic stenosis

23. REFERNCES
Agabegi SS, Agabegi ED. Step up to Medicine, 3rd ed Lippincott Williams & Wilkins. Philadelphia, PA.
Gomella LG, Haist SA. Basic EKG reading. In: Clinician’s Pocket Reference. McGraw-Hill; Accessed Nov 18, 2014.
Longo DL, Fauci AS, Kasper DL, et al. Electrocardiography. In: Harrison’s Principles of Internal Medicine, 18th ed McGraw Hill. New York, NY.
University of Illinois at Chicago. Online ICU Guidebook ver_442934/Image/1.1/residentguides/final/icuguidebo ok.pdf. Accessed December 1, 2014.