Bryan Heart. Unknown ECGs for the Clinician. Disclaimer 9/2/2015

Transcription

1 Bryan Heart Unknown ECGs for the Clinician 2015 Bryan Heart Fall Cardiology Conference Andrew Merliss, MD, FACC, CDRS, FHRS Director of Cardiac Arrhythmia Service Bryan Heart Disclaimer Advisory Board for Medtronic Co Clinical Research Projects Medtronic and St. Jude Co 1

2 Case presentation: 26 year old male gun salesman was driving west on route 80 near York when he woke up in a field No recollection of events No prior history of syncope or epilepsy No family history of syncope (no hxof QT, HCM) On no medications, has a normal PE and ECG Hobby of posting dash cam recordings on the internet of bad drivers and had a dash cam in his car. This patient: A. 1. Probably has epilepsy and had a seizure B. 2. Will probably need a pacemaker or a defibrillator even though he is only 26. C. 3. Has had several million hits when he posted this on YouTube. 1. Probably has epilepsy a.. 2. Will probably need a p Has had several million hi.. 2

3 Neurocardiogenic syncope Mechanism venous pooling VR and vigorous contraction of empty LV. This stimulates ventricular mechanoreceptors and afferent (C-fiber activity sympathetic inhibition and parasympathetic stimulation via NTS) Vasodilation (Vasodepressor type) Bradycardia, Heart Block (Cardioinhibitory) Mixed Hypotension, Syncope Tilt Table Test for Syncope Abnormal responses seen during positive tilt test: Hypotension (Vasodepressor) Cardioinhibitory(Brady, Heart block, asystole can be dramatic) Mixed 3

4 Tilt Table Response in Patient with Neurally- Mediated Syncope Sra JS. Ann Intern Med. 1991;114:

5 Treatment should include: A.Reassurance that recurrence is unlikely B. Beta blockers C.Beta blockers, midodrine, support hose, increased salt and volume intake Reassurance that recurrence... Beta blockers Beta blockers, midodrine,... The following ECG was taken on a previously healthy 24 year old medical student with a normal Physical Exam 5

6 Which of the following is true A. 1. He is unlikely to live into his sixties B. 2. He may have had a recent unrecognized PE C. 3. He has a high risk of needing a future pacemaker D. 4. He could never be accepted into the Air Force or Marine Corp with this ECG 1. He is unlikely to live into h.. 2. He may have had a recent He has a high risk of need He could never be accepte... If he had had a Pulmonary Embolus his rhythm would most likely be: A. 1. Normal sinus B. 2. Atrial fibrillation C. 3. Atrial flutter D. 4. Sinus tachycardia E. 5. Ventricular tachycardia 1. Normal sinus 2. Atrial fibrillation 3. Atrial flutter 4. Sinus tachycardia 5. Ventricular tachycardia 6

7 Right Bundle Branch Block A per 1000 healthy Air Force Personnel between age 16 and 55 B. 2. Higher incidence at altitude C. 3. Associated with acute MI, ASD, EbsteinsAnomaly, Chagas Dz, CMP 1.8 per 1000 healthy Air For.. 2. Higher incidence at altitude 3. Associated with acute MI,... The insect in the preceding slide is associated with the most common world wide cause of RBBB A. True B. False True False 7

8 The following ECG shows: A. 1. Obvious pacemaker malfunction B. 2. Proper pacemaker function 1. Obvious pacemaker malfu Proper pacemaker function This patient has: A. 1. Ventricular Tachycardia B. 2. An Acute MI C. 3. Bundle Branch Block D. 4. Coronary Spasm 1. Ventricular Tachycardia 2. An Acute MI 3. Bundle Branch Block 4. Coronary Spasm 8

9 This patient has: A. 1. Mobitz I B. 2. Mobitz II C. 3. Neither 1. Mobitz I 2. Mobitz II 3. Neither 9

10 This patient has: A. 1. Mobitz I block B. 2. Mobitz II block C. 3. Can t tell 1. Mobitz I block 2. Mobitz II block 3. Can t tell 10

11 This patient has: A. 1. Mobitz I block B. 2. Mobitz II block C. 3. Can t tell 1. Mobitz I block 2. Mobitz II block 3. Can t tell 11

12 This patient has: A. 1. Should be immediately defibrillated B. 2. Has clean teeth C. 3. Should be sent to the neurologist 1. Should be immediately de Has clean teeth 3. Should be sent to the neu... 12

13 This patient: A. 1. Is having a cardiac arrest B. 2. Has a disconnected ECG lead C. 3. Needs a defibrillator 1. Is having a cardiac arrest 2. Has a disconnected ECG lead 3. Needs a defibrillator 45 y.o. M with C/P, 95% RCA Rx stent post EF 45% He needs: A. 1. A life vest for 45 days then ICD B. 2. Immediate ICD implantation C. 3. No life vest, no ICD 1. A life vest for 45 days the Immediate ICD implantation 3. No life vest, no ICD 13

14 This patient: A. 1. Had a recent viral infection and now presents with pleuritic chest pain B. 2. Is having an MI C. 3. Is a healthy black male with early repolarization pattern 1. Had a recent viral infectio Is having an MI 3. Is a healthy black male wit... This patient: A. 1. Slow V-Tach (Idioventricular rhythm) B. 2. Is having an MI C. 3. Has atrial fibrillation and is having an MI 1. Slow V-Tach (Idioventricu Is having an MI 3. Has atrial fibrillation and.. 14

15 This patient: A. 1. Chest Pain B. 2. A headache 1. Chest Pain 2. A headache 15

16 This patient: A. 1. Chest Pain B. 2. A headache 1. Chest Pain 2. A headache 19 year old Black male collapsed playing basketball A. 1. Benign hypertrophy of healthy black males B. 2. Has untreated HTN and LVH C. 3. May have hypertrophic cardiomyopathy 1. Benign hypertrophy of he Has untreated HTN and LVH 3. May have hypertrophic c... 16

17 This patient A. 1. Is hyperkalemic B. 2. Is having an MI 1. Is hyperkalemic 2. Is having an MI 17

18 This patient A. 1. Hyperkalemic B. 2. Is having an acute MI 1. Hyperkalemic 2. Is having an acute MI This patient A. 1. Has hyperkalemia B. 2. Is having an MI 1. Has hyperkalemia 2. Is having an MI 18

19 This patient A. 1. Has bulimia and takes diuretics and laxatives B. 2. Is hyperkalemic and needs dialysis 1. Has bulimia and takes diur Is hyperkalemic and needs... If the patient: A. 1. Develops Atrial fibrillation give Sotololand then cardiovert B. 2. Develops pneumonia give erythromycin C. 3. Develops a fungal infection give Ketaconozole D. 4. Develops depression give Elavil E. 5. None of the above 2. Develops pneumonia give Develops Atrial fibrillation Develops depression give Develops a fungal infectio None of the above 19

20 Causes of QT prolongation A. 1. Congenital ion channelopathies B. 2. Drugs Acquired channelopathies C. 3. Electrolyte abnormalities 1. Congenital ion channelop Drugs Acquired channel Electrolyte abnormalities 20

21 This arrhythmia originated in the: A. 1. Atrium B. 2. Ventricle 1. Atrium 2. Ventricle This patient A. 1. Has V tach B. 2. Has SVT (with aberrancy) 1. Has V tach 2. Has SVT (with aberrancy) 21

22 He has an EF of 35%, has been on ACEI and BB for 3month and subsequently has an ICD implanted. Which of the following are true: A. 1. V tach may be terminated by anti tachy pacing B. 2. V tach can be terminated by ICD shock C. 3. The ICD can prevent Sudden Death by stopping a bullet D. 4. All are true 1. V tach may be terminated V tach can be terminated.. 3. The ICD can prevent Sudd.. 4. All are true ICD Therapies Differentiating VTach from SVT with aberrancy Width of QRS Bizarre axis AV dissociation Rabbit ears Concordant precordial QRS pattern 22

23 This patient A. 1. Needs a pacemaker B. 2. Needs a defibrillator 1. Needs a pacemaker 2. Needs a defibrillator 23

24 This patient A. 1. Has a fever of 102 and sinus tachycardia B. 2. Has SVT 1. Has a fever of 102 and sin.. 2. Has SVT This patient A. 1. Has WPW syndrome B. 2. Has a Left Bundle Branch Block 1. Has WPW syndrome 2. Has a Left Bundle Branch... 24

25 This patient A. 1. Atrial fibrillation B. 2. Ventricular tachycardia 1. Atrial fibrillation 2. Ventricular tachycardia 25