ECG S: A CASE-BASED APPROACH December 6,
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1 ECG S: A CASE-BASED APPROACH December 6,
2 Faculty Disclosure Faculty: Lorne Gula MD, FRCPC Professor, Western University Cardiologist, Hearth Rhythm Specialist Director, Electrophysiology Laboratory, London, Ontario Damian Redfearn MB, ChB, MRCPI, FRCPC Heart Rhythm Service, Kingston General Hospital Relationships with commercial interests: Not Applicable Potential for conflict(s) of interest: Not Applicable 2
3 Mitigating Potential Bias All the recommendations involving clinical medicine are based on evidence that is accepted within the profession. Recommendations conform to the generally accepted standards. The presentation will mitigate potential bias by ensuring that data and recommendations are presented in a fair and balanced way. 3
4 Learning Objectives After active participation in the workshop participants will be able to diagnose the following conditions on ECG and review principles of clinical management: Bradycardia, conduction abnormalities, and tachycardia. Myocardial ischemia, acute and previous myocardial infarction. Other systemic disorders with ECG manifestations. 4
5 58 year old man, chest pressure, short of breath 1. Pericarditis 2. Acute inferior MI 3. Acute anterior MI 4. Ventricular tachycardia
6
7 58 year old man, chest pressure, short of breath 1. Pericarditis 2. Acute inferior MI 3. Acute anterior MI 4. Ventricular tachycardia
8 52 year old woman with sudden shortness of breath. Most concerning abnormality is 1. Right bundle branch block 2. AV delay 3. Anteroseptal infarction 4. Brugada sign
9
10 52 year old woman with sudden shortness of breath. Most concerning abnormality is 1. Right bundle branch block 2. AV delay 3. Anteroseptal infarction 4. Brugada sign
11 64 year old man, hypertension, diabetes, short of breath 1. Inferior MI 2. Left bundle branch block 3. Diffuse ischemia 4. Complete AV block 5. None of above
12
13 64 year old man, hypertension, diabetes, short of breath 1. Inferior MI 2. Left bundle branch block 3. Diffuse ischemia 4. Complete AV block 5. None of above
14 48 year old man, prior MI and stent, sudden chest pressure 1. Acute anterior MI 2. Acute inferior MI 3. Pericarditis 4. Ventricular tachycardia 1/2
15
16 48 year old man, prior MI and stent, sudden chest pressure 1. Acute anterior MI 2. Acute inferior MI 3. Pericarditis 4. Ventricular tachycardia 1/2
17 2/2
18 22 yo healthy young man, recent URTI, now having chest pain 1. Hyperkalemia 2. Intracranial bleed 3. Pericarditis 4. Acute MI
19
20 22 yo healthy young man, recent URTI, now having chest pain 1. Hyperkalemia 2. Intracranial bleed 3. Pericarditis 4. Acute MI
21 67 year old man, hypertension, routine assessment 1. Left bundle branch block 2. Right bundle branch block 3. Ventricular rhythm 4. Atrial fibrillation
22
23 67 year old man, hypertension, routine assessment 1. Left bundle branch block 2. Right bundle branch block 3. Ventricular rhythm 4. Atrial fibrillation
24 1/2 68 year old woman, fatigue and dizziness past 2 weeks. This patient is at risk of 1.Bradycardia 2. Tachycardia 3. Both 4. Neither
25
26 1/2 68 year old woman, fatigue and dizziness past 2 weeks. This patient is at risk of 1.Bradycardia 2. Tachycardia 3. Both 4. Neither
27 2/2
28 54 yo man preop hand surgery. What is the rhythm? 1. Sinus 2. Junctional 3. AF 4. Ventricular 5. A flutter
29
30 54 yo man preop hand surgery. What is the rhythm? 1. Sinus 2. Junctional 3. AF 4. Ventricular 5. A flutter
31 72 yo woman, fatigue, poor energy level. What is the diagnosis? 1. Bradycardia 2. Atrial fibrillation 3. Complete AV block 4. All of the above 5. None of the above
32
33 72 yo woman, fatigue, poor energy level. What is the diagnosis? 1. Bradycardia 2. Atrial fibrillation 3. Complete AV block 4. All of the above 5. None of the above
34 63 year old man known to the heart rhythm service. Routine assessment. The rhythm is 1. Sinus with PVCs 2. AF with PVCs 3. AF with pacing 4. Idioventricular
35
36 63 year old man known to the heart rhythm service. Routine assessment. The rhythm is 1. Sinus with PVCs 2. AF with PVCs 3. AF with pacing 4. Idioventricular
37 62 year old man, referred by sleep clinic for rhythm assessment. The conduction disturbance is most likely 1. In the sinus node 2. In the AV node 3. In the distal conduction system 4. In the His Bundle
38
39 62 year old man, referred by sleep clinic for rhythm assessment. The conduction disturbance is most likely 1. In the sinus node 2. In the AV node 3. In the distal conduction system 4. In the His Bundle
40 71 year old woman, 2 episodes of syncope. The conduction disturbance is most likely 1.In the sinus node 2. In the AV node 3. In the distal conduction system 4. In the His Bundle
41
42 71 year old woman, 2 episodes of syncope. The conduction disturbance is most likely 1.In the sinus node 2. In the AV node 3. In the distal conduction system 4. In the His Bundle
43 2 AV block Some p waves conduct, some don t Within AV node Mobitz 1 ( Wenckebach ) pattern: Gradually prolonging PR until dropped QRS narrow QRS long-ish PR even on first beat of sequence) Low risk of worsening block/bradycardia Distal conduction system (below AV node) Mobitz II pattern: Constant PR with intermittently dropped QRS normal PR when conducted slightly wide QRS High risk of worsening block/bradycardia
44 2:1 AV conduction. The conduction disturbance is most likely 1.In the sinus node 2. In the AV node 3. In the distal conduction system 4. In the His Bundle
45
46 2:1 AV conduction. The conduction disturbance is most likely 1.In the sinus node 2. In the AV node 3. In the distal conduction system 4. In the His Bundle
47 The conduction disturbance is most likely 1.In the sinus node 2. In the AV node 3. In the distal conduction system 4. In the His Bundle
48 The AV conduction disturbance is 1.First degree AV delay 2. Second degree AV block 3. Complete AV block 4. Need more info
49
50 The AV conduction disturbance is 1.First degree AV delay 2. Second degree AV block 3. Complete AV block 4. Need more info
51 For clearer diagnosis it would be helpful to 1.Cardiovert 2. Pace 3. Intubate 4. Give adenosine
52
53 For clearer diagnosis it would be helpful to 1.Cardiovert 2. Pace 3. Intubate 4. Give adenosine
54 43 yo man, renal impairment, no coronary history 1. Hypokalemia 2. Left bundle branch block 3. Diffuse ischemia 4. Hyperkalemia 5. Hypocalcemia
55
56 43 yo man, renal impairment, no coronary history 1. Hypokalemia 2. Left bundle branch block 3. Diffuse ischemia 4. Hyperkalemia 5. Hypocalcemia
57 32 yo woman, syncope. Mild sharp pleuritic pain. 1. Hyperkalemia 2. Intracranial bleed 3. Brugada syndrome 4. Acute MI
58
59 32 yo woman, syncope. Mild sharp pleuritic pain. 1. Hyperkalemia 2. Intracranial bleed 3. Brugada syndrome 4. Acute MI
60 Wilde et al Circ 2002 ;106 :2514 Brugada Syndrome
61 Asymptomatic CCU patient needs immediate 1. Thrombolytic 2. Defibrillation 3. Nitro 4. Telemetry adjustment 5. Inotropes
62
63 Asymptomatic CCU patient needs immediate 1. Thrombolytic 2. Defibrillation 3. Nitro 4. Telemetry adjustment 5. Inotropes
64 Clues to artifact Messy baseline QRS tracks through at regular rate Nonphysiologic intervals No pause after resolution
65 1/2 35 yo woman, stable but palpitations 1. AV node reentry 2. AV reentry (WPW) 3. Preexcited AF 4. VT 5. Need more info
66
67 1/2 35 yo woman, stable but palpitations 1. AV node reentry 2. AV reentry (WPW) 3. Preexcited AF 4. VT 5. Need more info
68 2/2 Same patient, after adenosine. SVT was most likely 1. AV node reentry 2. AV reentry (WPW) 3. Atrial tachycardia 4. VT 5. Need more info
69
70 2/2 Same patient, after adenosine. SVT was most likely 1. AV node reentry 2. AV reentry (WPW) 3. Atrial tachycardia 4. VT 5. Need more info
71
72 1/2 30 yo woman, stable with palpitations. Initial tx: 1. Verapamil 2. Atenolol 3. Isoproterenol 4. Procainamide 5. Cardioversion
73
74 1/2 30 yo woman, stable with palpitations. Initial tx: 1. Verapamil 2. Atenolol 3. Isoproterenol 4. Procainamide 5. Cardioversion
75 2/2 Sinus rhythm AF
76 68 yo man, stable with palpitations. Most likely: 1. VT 2. SVT with BBB 3. Pre-excited tachycardia 4. Paced 5. Artifact
77
78 68 yo man, stable with palpitations. Most likely: 1. VT 2. SVT with BBB 3. Pre-excited tachycardia 4. Paced 5. Artifact
79 63 yo man, no cardiac history, stable with palpitations. Initial medication: 1. Verapamil 2. Amiodarone 3. Adenosine 4. Heparin 5. Procainamide
80
81 63 yo man, no cardiac history, stable with palpitations. Initial medication: 1. Verapamil 2. Amiodarone 3. Adenosine 4. Heparin 5. Procainamide
82 54 yo man, no cardiac history, palpitations. Cause of palpitations: 1. AV node pathology 2. PVCs 3. PACs 4. Sinus node dysfunction
83
84 54 yo man, no cardiac history, palpitations. Cause of palpitations: 1. AV node pathology 2. PVCs 3. PACs 4. Sinus node dysfunction
85
86
87 42 yo man, no cardiac history, recent echo normal. Stable with palpitations. 1. SVT with RBBB 2. Pre-excited tachycardia 3. VT 4. Pacing
88
89 42 yo man, no cardiac history, recent echo normal. Stable with palpitations. 1. SVT with RBBB 2. Pre-excited tachycardia 3. VT 4. Pacing
90 This pacemaker has: 1. One lead 2. Two leads 3. Three leads 4. Can t tell
91
92 This pacemaker has: 1. One lead 2. Two leads 3. Three leads 4. Can t tell
93
94
95 This pacemaker has: 1. One lead 2. Two leads 3. Three leads 4. Can t tell
96
97 This pacemaker has: 1. One lead 2. Two leads 3. Three leads 4. Can t tell
98
99
100 Biventricular pacemaker 1. Undersensing 2. Normal 3. Oversensing 4. Failure to capture
101
102 Biventricular pacemaker 1. Undersensing 2. Normal 3. Oversensing 4. Failure to capture
103 Questions/Discussion Lorne Gula, MD Director, Heart Rhythm Ablation Lab, London, Ontario Damian Redfearn, MB, ChB, MRCPI Director, Heart Rhythm Service, Kinston, Ontario
104 Questions? Lorne Gula, MD Director, Heart Rhythm Ablation Lab, London, Ontario Damian Redfearn, MB, ChB, MRCPI Heart Rhythm Service, Kinston, Ontario 104
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