ECGs on the acute admission ward. - Cardiology Update -
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1 ECGs on the acute admission ward - Cardiology Update - Dr Simon Fynn Consultant Cardiologist Papworth Hospital, Cambridge RCP London Oct 2017
2
3 ECG 1 1. AF with BBB 2. Pre-excited AF 3. SVT with BBB 4. VT 5. Antidromic tachycardia
4 ECG 1 1. AF with BBB 2. Pre-excited AF 3. SVT with BBB 4. VT 5. Antidromic tachycardia
5 ECG 1 FF F F F F C C
6 Broad Complex Tachycardia VT SVT with BBB SVT with preexcitation oddities
7 Broad Complex Tachycardia
8 SIMPLE WAYS (!) TO DIAGNOSE VT QRS complex duration > 140 msec (0.14 sec) QRS axis to Rs, R qr in V 1 R, qr, Qr, QR in V 6 LBBB + RAD Concordant R waves in precordial leads Predominantly negative QRS in I, II and III Q waves in precordial leads AV dissociation Fusion beats Capture beats Absence of RS in precordial leads QRS narrower in tachycardia than in SR Contralateral BBB in SR and BCT QRS alternans Multiple WCT configurations Brugada algorithm (and other algorithms)
9 SIMPLE (!) WAYS TO DIAGNOSE VT QRS complex duration > 140 msec (0.14 sec) QRS axis to Rs, R qr in V 1 R, qr, Qr, QR in V 6 LBBB + RAD Concordant R waves in precordial leads Predominantly negative QRS in I, II and III Q waves in precordial leads AV dissociation Fusion beats Capture beats Absence of RS in precordial leads QRS narrower in tachycardia than in SR Contralateral BBB in SR and BCT QRS alternans Multiple WCT configurations Brugada algorithm (and other alorithms) These are the only 3 that do not depend on the QRS waveform
10 Carotid Sinus Massage during BCT I avf V 1 From Miller et al. Cardiac EP: from Cell to Bedside 4 th Ed p
11 VA dissociation I avf?? V 1 VA block with uninterrupted BCT = ventricular tachycardia
12 / QS Typical BBB
13 RBBB V 1 normal V 1 - in RBBB (fixed or rate-related) V 1 - unacceptable waveforms in RBBB (fixed or rate-related) Dominant primary R wave (Rr, R) is likely to be VT
14 Adenosine use in BCT - is this always safe? -? Terminate tachycardia? Elucidate mechanism of tachycardia
15 cases from this week..
16
17 49 yr old female Been a patient in heart failure clinic for 10 years Palps for few hours ECG shows BCT - atypical RBBB
18 49 yr old female Been a patient in heart failure clinic for 10 years Palps for few hours ECG shows BCT - atypical RBBB
19 Given adenosine Cardiac arrest
20
21 71 yr old male MI 10 yrs ago Palps for few hours ECG shows BCT - atypical LBBB
22 71 yr old male MI 10 yrs ago Palps for few hours ECG shows BCT - atypical LBBB
23 DC CV SR, anterior Q waves
24
25 24 yr old male No PMH / FH Palps for few hours ECG shows BCT- typical RBBB but bizarre axis.? Fascicular VT
26 EP study yesterday SVT (AVNRT) with BBB!!
27 Practical Approach to Diagnosis Rapid, straightforward and accurate approach is key If the BCT ECG does not conform to any known pattern of aberration, it is unlikely to be SVT with aberration! Either learn the typical patterns of aberration or learn an algorithm. Ideally learn both! Antiarrhythmic drugs can produce peculiar patterns of aberration If unsure, treat the patient with a BCT as though it is VT as this is by far the most common diagnosis
28 ECG 2 1. Do nothing 2. Arrange DC CV 3. Give amiodarone 4. Give flecainide 5. Give beta blockers
29 ECG recorded 30 minutes later
30 ECG 2 1. Do nothing 2. Arrange DC CV 3. Give amiodarone 4. Give flecainide 5. Give beta blockers
31 Typical atrial flutter -intracardiac electrograms- H 9-10 H 1-2
32 Typical Atrial Flutter
33 Typical Atrial Flutter
34 Typical Atrial Flutter - sites for ablation -
35 ECG 3 Atrial arrhythmia 2 weeks after AF ablation procedure 1. Sinus tachycardia 2. Atrial tachycardia with 2:1 conduction 3. Atrial tachycardia with 1:1 conduction 4. Atrial flutter 5. Atrial fibrillation
36 ECG 3 Atrial arrhythmia 2 weeks after AF ablation procedure 1. Sinus tachycardia 2. Atrial tachycardia with 2:1 conduction 3. Atrial tachycardia with 1:1 conduction 4. Atrial flutter 5. Atrial fibrillation
37 AF ablation strategies
38 Supraventricular tachycardia - terminate? - mechanism?
39 AVNRT Adenosine Vagal manoeuvres AVRT X A Tach X X
40 AV block following adenosine administration
41 ECG AF AF with BBB VT SVT with BBB Pre-excited AF
42 ECG AF AF with BBB VT SVT with BBB Pre-excited AF
43 Pre-excited AF DO NOT GIVE ADENOSINE!
44
45 Can I have an appt please, I am not not feeling very well
46 Pre-excited AF VF
47 Post defibrillation Post defibrillation
48 Ablation of left sided AP Ablation catheter Transeptal puncture
49 Post ablation
50 Orthodromic re-entrant tachycardia
51 Antidromic re-entrant tachycardia
52 ECG 5 1. Artefact 2. AF with BBB 3. VT 4. SVT with BBB 5. Pre-excited AF
53 ECG 5 1. Artefact 2. AF with BBB 3. VT 4. SVT with BBB 5. Pre-excited AF
54 Artefact
55 ? Non-sustained VT
56 Artefact
57 ECG 6 41 yr old male resuscitated from VF next step? Thrombolyse Activate local PPCI pathway Contact on-call PCI Dr Contact on-call EP Dr Repeat ECG
58 ECG 6 41 yr old male resuscitated from VF next step? Thrombolyse Activate local PPCI pathway Contact on-call PCI Dr Contact on-call EP Dr Repeat ECG
59 Brugada syndrome
60 Long history of collapse! ECG 1997
61 Brugada and Phenocopies
62
63 ST elevation in V1..and avr
64
65 ECG 7 21 yr old female admitted after collapse next step? Normal ECG Sinus tachycardia Sinus arrhythmia Long QT ECG suggestive of PE
66 ECG 7 21 yr old female admitted after collapse next step? Normal ECG Sinus tachycardia Sinus arrhythmia Long QT ECG suggestive of PE
67 Measuring QT interval Summary: borderline normal QTc:600ms
68 Torsades de pointes
69 Thank you
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