INTERESTING ECGS. Wide-complex tachycardias 11/13/ yr male with acute ant wall MI, S/P primary PTCA

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1 INTERESTING ECGS V S Prakash Prof, & Head Dept. of Cardiology M S Ramaiah Hospitals 50 yr male with acute ant wall MI, S/P primary PTCA Pt. underwent successful PAMI An hour later,in the CCU Ventricular tachycardia POSSIBILITIES Sinus tachycardia SVT with aberrancy Idioventricular rhythm None of the above 1

2 Rate > 100 beats per minute QRS duration > 120 msec Atrial Any SVT with aberrant conduction (e.g., bundle-branch block) Any SVT conducting over an accessory pathway (e.g., atrial fibrillation in WPW) Ventricular Ventricular tachycardia (monomorphic, idiopathic) Accelerated idioventricular rhythm (AIVR) Pacemaker-mediated tachycardia Torsades de pointes Ventricular fibrillation a systematic approach Review the clinical data Recognize at first glance Find the P wave Match P s and QRS s Pinpoint the diagnosis Confirm a systematic approach Review the clinical data Recognize at first glance Find the P wave Match P s and QRS s Pinpoint the diagnosis Confirm Patients with heart disease and WCT: ~95% VT a systematic approach Review the clinical data Recognize at first glance Find the P wave Match P s and QRS s Pinpoint the diagnosis Confirm 2

3 recognize at first glance recognize at first glance Undulating QRS amplitude ( twisting of the points ) A 72-year-old woman with Occurs coronary in prolonged artery QT (congenital disease or and drugrelated) admitted with nausea depression Rate > 200 and lightheadedness High risk of sudden death Torsades-de-pointes ventricular tachycardia (patient on tricyclic, baseline QT 710 ms) recognize at first glance 67-year-old man one hour after presenting w/stemi VENTRICULAR FIBRILLATION Results from multiple reentrant wavelets in the ventricle Usually occurs with structural heart disease Rate > 300 Rapidly lethal if not defibrillated a systematic approach Review the clinical data Recognize at first glance Find the P wave Match P s and QRS s Pinpoint the diagnosis Confirm Find the P waves Find the P waves 3

4 Find the P waves Find the P wave / Match P s & QRS s AV dissociation virtually diagnostic of VT But only apparent in ~1/3 of WCT due to VT Capture and fusion beats seen in VT: When a dissociated P wave causes total (capture) or partial (fusion) activation of the ventricle in advance of the next beat 66 yo man with palpitations and syncope Regular rhythm 120 beats/min Wide QRS AV dissociation dissociated P s Fusion complexes a systematic approach Review the clinical data Recognize at first glance Find the P wave Match P s and QRS s Confirm Pinpoint the diagnosis What s left?... Distinguishing VT from SVT with aberrant conduction SVT with aberrancy Atrial rhythms 1. Atrial tachycardia 2. Sinus tachycardia 3. Atrial flutter 4. Atrial fibrillation Nodal Tachycardias 1. AVNRT 2. Automatic junctional tachycardia Accessory pathwaymediated RBBB LBBB 4

5 Closer look at QRS: compare to sinus QRS Tachycardia QRS morphology similar to QRS complexes in normal sinus rhythm: favors SVT with aberrant conduction Tachycardia QRS morphology resembling PVCs seen in normal sinus rhythm: favors VT Tachycardia QRS narrower than sinus QRS: favors VT 56 yr female underwent successful PTCA to a totally occluded LCX Mid RCA - 80% stenosis planned for staged PTCA 4 hrs later in the CCU What is to be done Emergency Coronary angio? True posterior wall MIpossible occlusion of RCA? Acute Stent thrombosis 55 yr female, ACS -totally occluded LCX. Successful PCI, however complicated by transient no-flow 5

6 Accelerated Idioventricular Rhythm (AIVR) Arises from ventricle (Purkinje fibers) Generally peri-infarct rhythm Rate Regular, wide QRS Generally self-terminating Not necessarily an indicator of reperfusion Retrograde P waves Closer look at QRS: compare to sinus QRS Tachycardia QRS morphology similar to QRS complexes in normal sinus rhythm: favors SVT with aberrant conduction Tachycardia QRS morphology resembling PVCs seen in normal sinus rhythm: favors VT Tachycardia QRS narrower than sinus QRS: favors VT Sinus rhythm with a wide QRS complex because of anterolateral MI and pronounced delay in left ventricular activation VT arising from right side of septum: more simultaneous activation of R & L ventricles than sinus rhythm, and therefore a narrower QRS. a systematic approach Review the clinical data Recognize at first glance Find the P wave Match P s and QRS s Pinpoint the diagnosis Confirm VT or SVT? Palpitations in a 23 year old What is this? 6

7 Feeling lost! Confirm Termination or increased AV block with carotid sinus massage or other vagal stimulation: suggests SVT Adenosine-induced termination: suggests SVT But some VTs are adenosine sensitive Response to other antiarrhythmic drugs generally not helpful EPS can provide definitive confirmation if WCT is inducible. IV Adenosine IV verapamil or diltiazem DC cardioversion IV digoxin TREATMENT After IV adenosine What is this? IV Adenosine What is the diagnosis? Is like bringing a knife to a gunfight Is it? 7

8 AF VF Courtesy of Dr. Brian Olshansky. a systematic approach Review the clinical data Recognize at first glance Find the P wave Match P s and QRS s Pinpoint the diagnosis Confirm Confirm Diagnostic Electrophysiology Study 8

9 56 yr male S/P CABG Summary 46 yr male with H/O retrosternal chest pain of 2 hrs duration Consider all wide-complex tachycardia VT until proven otherwise. In unselected patients with WCT, 80% are VT. In patients with heart disease, 95% are VT. VT can be associated with a normal BP. ECG criteria to distinguish VT from SVT are not 100% sensitive & specific. Acute anteroseptal MI Acute inferior wall MI None of the above Don t Know 9

10 PERICARDITIS 46 yr female, known case of acyanotic CHD, C/O dyspnoea, giddiness What are the ECG findings I saw it, but did not realize it! Sinus bradycardia Rt. Bundle branch block with LAHB Junctional rhythm Infero-posterior with lateral wall MI of indeterminate age None of the above 10

11 24 yr male with recurrent palpitations ECG in the ER What is the diagnosis? Atrial tachycardia Sinus tachycardia Atrial flutter SVT with block None of the above Aiming at the wrong target? 11

12 64 yr female, RHD ; on AADs In the ICU that night Short- long short cycles in the background of QT What went wrong? Why did she develop that near fatal arrhythmia Thank You! I saw it, but did not realize it! Elizabeth Peabody 12

13 speaker Questions? Flash Quiz Read the ECG Rate? Regularity? P waves? PR interval? QRS duration? Interpretation? 70 bpm regular flutter waves none 0.06 s Atrial Flutter Flash Quiz Read the ECG Ventricular tachycardia Rate? Regularity? P waves? PR interval? QRS duration? Interpretation? none irregularly irreg. none none wide, if recognizable Ventricular Fibrillation RBBB superior axis pattern CASE 1 13

14 Flash Quiz To minimize motion artifacts, electrodes should? a. Be taken from vacuum sealed packages b. Be moistened with saline prior to placement c. Be further reinforced with tape or glue d. Be cleared of skin that has been cleared of dead cells & hair e. Have plenty of gel and replaced if soiled or wet Ans. a, d, e! Lead II is well established for dysrhythmia monitoring? True or False Ans. False Lead V1 is well established for dysrhythmia monitoring Flash Quiz The horizontal millimeter of ECG paper measures? a seconds b millivolt c. 1/25 of a second d. 0.1 millivolt Ans. b, c The verticle millimeter of ECG paper measures? a seconds b. 1 millivolt c. 0.1 millivolt d millivolt Ans. c 1 mm width = 1/25 second = 0.04 seconds = 40 milliseconds 1 mm width = 0.1 millivolt 59 yr male,s/p PTCA to RCA 6 mths prior presents with chest discomfort Pt. underwent succesful PAMI An hour later,in the CCU 14

15 75 yo female - palpitations Fairly typical QRS for a RBBB 65 yo male with palpitations VT or SVT? A Wide QRS Tachycardia Adenosin 6 mg iv. 15

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17 Flash Quiz Read the ECG Flash Quiz Read the ECG Rate? Regularity? P waves? PR interval? QRS duration? Interpretation? 70 bpm regular flutter waves none 0.06 s Atrial Flutter Rate? Regularity? P waves? PR interval? QRS duration? Interpretation? none irregularly irreg. none none wide, if recognizable Ventricular Fibrillation Rate > 100 beats per minute QRS duration > 120 msec Flash Quiz To minimize motion artifacts, electrodes should? a. Be taken from vacuum sealed packages b. Be moistened with saline prior to placement c. Be further reinforced with tape or glue d. Be cleared of skin that has been cleared of dead cells & hair e. Have plenty of gel and replaced if soiled or wet Ans. a, d, e! Lead II is well established for dysrhythmia monitoring? True or False Ans. False Lead V1 is well established for dysrhythmia monitoring 17

18 Flash Quiz The horizontal millimeter of ECG paper measures? a seconds b millivolt c. 1/25 of a second d. 0.1 millivolt Ans. b, c The verticle millimeter of ECG paper measures? a seconds b. 1 millivolt c. 0.1 millivolt d millivolt Ans. c 1 mm width = 1/25 second = 0.04 seconds = 40 milliseconds 1 mm width = 0.1 millivolt Atrial Any SVT with aberrant conduction (e.g., bundle-branch block) Any SVT conducting over an accessory pathway (e.g., atrial fibrillation in WPW) Ventricular Ventricular fibrillation Torsades de pointes Ventricular tachycardia (monomorphic, idiopathic) Accelerated idioventricular rhythm (AIVR) Pacemaker-mediated tachycardia a systematic approach recognize at first glance Review the clinical data Recognize at first glance Find the P wave Match P s and QRS s Pinpoint the diagnosis Confirm recognize at first glance Undulating QRS amplitude ( twisting of the points ) A 72-year-old woman with Occurs coronary in prolonged artery QT (congenital disease or and drugrelated) admitted with nausea depression Rate > 200 and lightheadedness High risk of sudden death recognize at first glance 67-year-old man one hour after presenting w/stemi VENTRICULAR FIBRILLATION Torsades-de-pointes ventricular tachycardia (patient on tricyclic, baseline QT 710 ms) Results from multiple reentrant wavelets in the ventricle Usually occurs with structural heart disease Rate > 300 Rapidly lethal if not defibrillated 18

19 What s left?... Ventricular tachycardia Distinguishing VT from SVT with aberrant conduction RBBB superior axis pattern SVT with aberrancy Atrial rhythms 1. Atrial tachycardia 2. Sinus tachycardia 3. Atrial flutter 4. Atrial fibrillation RBBB Nodal Tachycardias 1. AVNRT 2. Automatic junctional tachycardia Accessory pathwaymediated LBBB Probability Unselected patients with WCT: ~80% VT Patients with heart disease and WCT: ~95% VT Clinical pearls: VT can be associated with a normal blood pressure. Misdiagnosing SVT as VT is generally benign. The reverse can be catastrophic. Agents to treat SVT (e.g., verapamil or diltiazem) may precipitate hemodynamic collapse in VT. ECG regularity VT is usually regular Caveat: Irregularity may be seen at onset and termination. Grossly irregular WCT most likely atrial fibrillation with conduction over an AP or aberrancy Caveat: Rarely, grossly irregular WCT may be atypical VT (polymorphic VT, VF, other rare VTs). 19

20 Find the P wave / Match P s & QRS s AV dissociation virtually diagnostic of VT But only apparent in ~1/3 of WCT due to VT Capture and fusion beats seen in VT: When a dissociated P wave causes total (capture) or partial (fusion) activation of the ventricle in advance of the next beat 66 yo man with palpitations and syncope Regular rhythm 120 beats/min Wide QRS AV dissociation dissociated P s Fusion complexes Closer look at QRS: compare to sinus QRS VT 1-to-1 VA conduction Tachycardia QRS morphology similar to QRS complexes in normal sinus rhythm: favors SVT with aberrant conduction Tachycardia QRS morphology resembling PVCs seen in normal sinus rhythm: favors VT Tachycardia QRS narrower than sinus QRS: favors VT Sinus rhythm with a wide QRS complex because of anterolateral MI and pronounced delay in left ventricular activation VT arising from right side of septum: more simultaneous activation of R & L ventricles than sinus rhythm, and therefore a narrower QRS. Closer look at QRS: Axis Normal QRS axis suggests SVT with aberrant conduction Left- or right-axis deviation favors VT Extreme left- or right-axis deviation strongly suggests VT VT 0 o SVT 20

21 66 yo man with palpitations and syncope Closer look at QRS: Duration Right-axis deviation If RBBB pattern, QRS > 140 msec suggests VT If LBBB pattern, QRS > 160 msec suggests VT QRS > 160 msec suggests VT regardless of QRS morphology Exceptions exist, particularly in patients on antiarrhythmics 66 yo man with palpitations and syncope Closer look at QRS: Concordance RBBB morphology QRS duration 152 msec Definition: All QRS complexes from V 1 through V 6 are either upright or inverted. Negative concordance is virtually diagnostic for VT. Positive concordance suggests VT. But also may seen in patients with antidromic reciprocating tachycardia 66 yo man with palpitations and syncope Closer look at QRS: Morphology Positive QRS concordance in precordial leads RBBB WCT: VT is suggested by monophasic or biphasic QRS in V 1 R:S ratio < 1 in V 6 LBBB WCT: VT is suggested by V 1 : R > 30 ms, S > 70 ms, or notched S V 6 : qr pattern 21

22 66 yo man with palpitations and syncope RBBB morphology Monophasic QRS in V 1 Closer look at QRS: Morphology (cont d) LBBB WCT: VT is suggested by notch R > 30 ms S > 70 ms Closer look at QRS: Morphology (cont d) Confirm AMI qr complexes suggest VT qr complexes indicate scar They are present in approximately 40% of VTs after myocardial infarction IMI Termination or increased AV block with carotid sinus massage or other vagal stimulation: suggests SVT Adenosine-induced termination: suggests SVT But some VTs are adenosine sensitive Response to other antiarrhythmic drugs generally not helpful EPS can provide definitive confirmation if WCT is inducible. Diagnostic Electrophysiology Study Diagnostic EP study Unexplained syncope in the presence of structural heart disease Documented wide-qrs tachycardia Prior sudden cardiac death Sustained supraventricular arrhythmias and PSVT Prior to, and in association with, catheter ablation procedures Risk stratification of patients with impaired ventricular function, NSVT, (EF>35%). 22

23 EP study induction of VT with ventricular extrastimuli EP study confirmation with intracardiac electrograms Surface ECG Surface ECG Catheter in atrium Catheter at His Bundle Catheter in ventricle Catheter in ventricle VT flavors Monomorphic VT Idiopathic VT Accelerated idioventricular rhythm (AIVR) Dissociated P waves Monomorphic VT Arises from the ventricle (usually infarct scar) Rate Regular wide QRS High risk of sudden death, especially in poor LV function Idiopathic VT arising from RV outflow tract Usually from RVOT (LBBB morphology) Occurs with increased sympathetic tone (exercise) Patients have normal LV function Rate Regular wide QRS Benign arrhythmia, good prognosis Accelerated Idioventricular Rhythm (AIVR) Arises from ventricle (Purkinje fibers) Generally peri-infarct rhythm Rate Regular, wide QRS Generally self-terminating Not necessarily an indicator of reperfusion Retrograde P waves 23

24 Diagnostic Algorithm Wide QRS complex tachycardia (QRS duration longer than 120 ms) Regular or irregular? VT Management Algorithm Regular Vagal maneuvers or adenosine VA dissociation? No QRS morphology in precordial leads Is QRS identical to that during SR? If yes, consider: SVT and BBB Antidromic AVRT Previous myocardial infarction or structural heart disease? If yes, VT is likely. Yes V rate faster than A rate VT Irregular Atrial fibrillation Atrial flutter / AT with variable conduction and a) BBB or b) antegrade conduction via AP A rate faster than V rate Atrial tachycardia Atrial flutter Structurally normal heart Beta blockers Antiarrhythmics Catheter ablation Reassurance LV EF 35% LV EF 35% Reversible cause? EP study yes Correct no No VT + VT Typical RBBB or LBBB SVT Precordial leads Concordant* No R/S pattern Onset of R to nadir longer than 100 ms VT RBBB Pattern qr, Rs or Rr 1 in V 1 Frontal plane axis range from +90 degrees to - 90 degrees VT LBBB pattern R in V 1 longer than 30 ms R to nadir of S in V 1 greater than 60 ms qr or qs in V 6 VT Beta blockers Antiarrhythmics ICD Practice Tracing #1 String Galvanometer Willem Einthoven Einthoven W. Archiv fur die Gesammte Physiologie des Menschen und der Thiere :473. Practice Tracing #1 Practice Tracing #2 WCT: VT most likely Rate 120: no help Regular? Yes = no help AV dissoc: not seen Axis: nl = no help QRSd: 200 ms > 160 = VT QRS concordance: no QRS morph: r > 30, S > 70 ms = VT Conclusion: VT 24

25 Practice Tracing #2 Practice Tracing #3 WCT: VT most likely Rate 280: no help Regular? no = suspect A-fib AV Dissoc: not seen Axis: LAD = may be VT QRSd: 130 ms < 160 = SVT QRS concordance: no QRS morph: r < 30 ms, S < 70 ms = SVT Conclusion: SVT / AF with WPW (posteroseptal AP) Practice Tracing #3 Practice Tracing #4 WCT: VT most likely Rate 290: no help Regular? yes = no help AV Dissoc: not seen Axis: nl (-60), suggests VT QRSd: 200 ms > 140 = VT QRS concordance: yes = VT QRS morph: monophasic R in V 1 = VT Conclusion: VT Practice Tracing #4 Practice Tracing #5 WCT: VT most likely Rate 120: no help Regular: yes = no help AV Diss: not seen Axis: nl = -80, suggests VT QRSd: 130 ms < 160 = SVT QRS concordance: yes = VT QRS m: r < 30ms, S = 70, no QR in V6 = SVT Conclusion: SVT (LBBB aberration) 25

26 Practice Tracing #5 Practice Tracing #6 WCT: VT most likely Rate 170: no help Regular: yes = no help AV Diss: yes = VT Axis: nl = SVT QRSd: 180 ms > 160 = VT QRS concordance: no QRS m: no r, S > 70 ms, notch = VT Conclusion: VT Practice Tracing #6 Practice Tracing #7 WCT: VT most likely Rate 150: no help Regular? yes = no help AV Dissoc: no = no help Axis: 100 = VT QRSd: 160 ms > 140 = VT QRS concord: yes = VT QRS morph: mono R in V = VT 1 Conclusion: VT Practice Tracing #7 WCT: VT most likely Rate 125: no help Regular? yes = no help AV dissoc: yes = VT Axis: nl = -60, suggests VT QRSd: 200 ms > 160 = VT QRS concordance: yes = VT QRS morph: R > 30ms, S > 70 ms in V 1 = VT Conclusion: VT 26

27 ECG recorded after IV adenosine What is the arrhythmia? Ventricular tachycardia Sinus tachycardia SVT with aberrancy Idioventricular rhythm None of the above 27

28 38 yo Female - FC IV CHF Will Adenosine Treat This? 28