ECG Workshop. Carolyn Shepherd And Anya Horne UWE Principles of Cardiac Care

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1 ECG Workshop Carolyn Shepherd And Anya Horne UWE Principles of Cardiac Care

2 ECG workshop case study1 44 Year old male. Reports SOB, Lethargy, tiredness. PMH: Hypertension, nil else. What tests? What treatment?

3 Case study 1 This ECG shows typical atrial flutter. Tests: ECHO, ambulatory monitoring, stroke risk assessment. Treatment: Consider, is the patient symptomatic? Medications (Beta blocker, calcium channel blocker) DCCV Catheter ablation

4 ECG Case study 2 34 Year Old Male, Sudden onset palps. Feels unwell, hypotensive, lightheaded. What acute treatment? What further tests/treatment?

5 Case study 2 This ECG shows pre-excited AF. WPW syndrome, accessory pathway that can conduct rapidly from A V Very high risk of VF while in AF Acute treatment: DCCV or IV flecainide if safe For patients in AF with WPW DONT give adenosine or verapamil!! Unless you have patient attached to defibrillator and are competent to use it! This case study is already worse case scenario! After initial cardioversion: Medication (Flecainide, beta blocker) ECHO, resting ECG (SR), Catheter ablation safest option.

6 ECG workshop Case Study 3 83 Year old women, dizzy spells, near syncope. PMH: MI 10 years ago, CABG. What acute treatment? What further tests/treatment?

7 Case study 3 This ECG shows Broad Complex Tachycardia Signs of true VT: Fusion/capture beats. Concordance in chest leads? Slurred rather than sharp onset. Treatment: Cardioversion either chemically or electrically first and stabilise Tests: ECHO, angiogram, troponin Treatment: If mod severe or severe LV impairment then for ICD. Medications: Amiodarone, beta blockers Consider catheter ablation in VT problematic and multiple device activations

8 ECG workshop and Case study 4 24 Year old male, palps on exercise. Feels dizzy, lightheaded. PMH: Nil. What tests/treatment?

9 Case Study 4 This ECG shows a clear delta wave (pre excitation) With the presence of tachycardia this is WPW syndrome Tests: ECHO, ambulatory monitoring.?ett? EPS/catheter ablation Consider: Why is this more serious than ordinary SVT?

10 ECG case study 5 17 year old female. OP clinic. Palps for last 3 months. Sudden onset. This is resting ECG. What tests/treatment?

11 Case Study 5 This ECH shows broad complex tachycardia. Inferior axis, left bundle branch pattern (so coming from right ventricle) This is Right Ventricular Outflow Tract Tachycardia (RVOT) Usually normal heart VT ECHO/MRI Rule out ARVC Medications: Betablockers Catheter ablation

12 ECG Case Study 6 76 yr old woman with breathlessness

13 Case Study 6 This ECG shows Atrial Fibrillation NICE guidelines. June 2006 Assess stroke risk. CHADS2 Control rate. β blockers/ca++ antagonists Consider Cause. Hypertension/IHD/Thyroid/Valves TFTs/Echo/Ambulatory monitoring Is patient symptomatic? Cardioversion. Ablation Paroxysmal/ablation frontiers. 90% cure Persistent/cartomerge 70% cure Ablate and pace.(ppm)

14 Atrial fibrillation Treatment Strategy

15 ECG Case Study 7 20 year old woman with palpitations

16 Case study 7 This ECG shows Supraventricular Tachycardia. This is not life threatening.? AVNRT/?AVRT. Tests. 12 lead ECG/ambulatory ECG/ TFTs /EP study? Treatment. Acute vagal manoevres/adenosine Long term. Do nothing/pill in pocket/regular medication(bb,ca++, Flecainide in normal heart. (Echo?) EPS+/-ablation. >90% success rate.

17 ECG Case Study 8 18 year old man with episodic syncope

18 Case Study 8 This ECG shows Long QT syndrome. Normal QTc >450ms men. >470 women using Bazett's formula Acquired or inherited (Autosomal dominant) Review of meds/electrolytes/ PMH/ and family history. Symptoms Swimming and exercise/auditory triggers/sleep. Echo/holter monitor. ETT- (changes in QTc/alt diagnosis. Risk stratification Schwartz score β blocker?ppm?icd Avoidance of certain drugs Referral to genetics team.

19 Long QT - Types

20 Torsades de Pointes

21 Case study 9 82 year old man with syncope

22 Case study 9 This ECG shows. Complete heart block with RBBB and LAD Symptoms? Review Medications. Echo. Class 1 indication for pacing PPM- Dual Chamber

23 Case Study year old man with syncope

24 Case Study 10 This ECG shows Brugada Syndrome Inherited genetic defect of Sodium channel. Autosomal dominant. High risk of Sudden Cardiac Death. Family history? Symptoms?. Ajmaline/Flecainide challenge? Risk assessment. High risk if previous cardiac arrest or spontaneous Type 1 pattern Exclude ARVC (SCN5a gene) Implanted Cardiac Defibrillator If young,symptomatic or FH sudden death or > 1 case in family, refer for genetic testing

25 Brugada Types

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