ECG Workshop. Nezar Amir

Transcription

1 ECG Workshop Nezar Amir

2 Myocardial Ischemia

3 ECG Infarct ECG in STEMI is dynamic & evolving

4 Common causes of ST shift

5 Infarct Localisation Left main artery occlusion: o diffuse ST-depression with ST elevation in AVR o very high risk Anterior wall: o ST elevation V1-V4. LAD. (often tachycardia) Inferior wall: o o ST elevation II, III, AVF. 80% RCA (elevation III>II; depression > I or in AVL), or RCX ( in 20%). (often bradycardic due to sinus node or AV node ischemia) Right ventricle infarct: o ST elevation in V4R. Posterior wall: o high R and ST-depression in V1-V3 Lateral wall: o ST elevation in lead I, AVL, V6. o LAD (D-branch)

6 Differential diagnosis of ST elevation 1:LVH 2:LBBB 3: Pericarditis 4: High Potassium 5: Acute AS infarct 6:: Acute AS infarct + RBBB 7: Brugada syndrome

7 Case Studies

8 Sixty year old male with epigastric pain associated with nausea and vomiting. Chronic smoker. HbA1c of 65. BP is 90/70 Q. All of the following are true, except? 1. Patient has acute pericarditis 2. Patient sustained acute MI and needs to be transferred to hospital 3. RV infarct is likely complication of this infarct 5. Emergency angioplasty is highly likely required in the coming 60 minutes 6. Heart block is likely complication

9 Same patient had right-sided leads showing RV infarct

10 Q-WAVES Q waves are electrically silent areas Sign of old MI Pathological Q Locations Any in V2-V3 >=0.03s and >0.1mV deep in other leads Two contiguous leads

11 72 year old man presented for a well check Q. The following are appropriate actions 1. Referral to hospital, this patient had MI 2. Risk factor assessment and referral to cardiac services ETT and echocardiography 3. No action, this ECG is normal

12 Q-Waves

13 55 year old male smoker, presented with central chest pain of 60 minutes. Patient was apprehensive and diaphoretic, BP; 100/60, exam is otherwise normal. Q. The following statement(s) in regards to ECG are true, except; 1. Patient sustained inferior STEMI 2. Patients sustained posterior STEMI 3. Patient sustained anterolateral STEMI 4. Immediate transfer on P1 ambulance is mandatory 5. Pain relief, morhpine, GTN and 600mg of chewable aspirin should be given

14 12 months later, the patient had an echocardiogram, and he comes back asking you to look up the result before him being seen by his cardiologist. He requested an ECG for reassurance Q. The findings on the ECG are; 1. New LBBB 2. Persistent ST elevation with biphasic T wave in the anterior leads 4. You predict that he would have a large septal scar on his echocardiogram 5. Patient had another STEMI, consider immediate transfer to hospital

15 48 year old healthy male presented with severe left-sided chest pain. The patient needed 15mg of Morhpine. 1st Troponin was negative. Q. The following are appropriate actions; 1. Obtain CT scan to exclude aortic dissection 2. Obtain echocardiogram to look for regional wall motion abnormalities 3. Obtain urgent second Troponin 4. Review all primary data, including history, family history, CXR, and blood test 5. Request psychiatrist support, this patient is a drug seeker

16 CT showed no dissection- done 10 minutes after arrival 2 nd Troponin showed no change from 1 st - time between the 2 tests in 45 minutes Patient is a father of three, farmer. Bloods and CXR are normal Urgent echocardiogram was obtained

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19 ST elevation in the absence of an ami Pericarditis/myocarditis. Left ventricular hypertrophy (LVH) Physiological/benign ST elevation Cardiac aneurysm Hyperkalemia LBBB HCM

20 50 year old healthy banker presenting for routine medical check. Asymptomatic. Non-smoker, no family history of cardiac disease Q. The best description for the ECG is; 1. RBBB 2. LBBB 3. Old anterior MI with aneurysm 4. LVH 5. Pericarditis

21 66 year old male with near syncope. Cardiac exam showed systolic murmur radiating to the carotids. BP is 110/70. No family history of SCD. Q. The best description for the ECG is; 1. LVH 2. LBB 3. NSTEMI 4. Old MI with Q waves 5. Pericarditis

22 66 year old male with near syncope. Cardiac exam showed systolic murmur radiating to the carotids. BP is 110/70. No family history of SCD. Q. The patient may be suffering from all except; 1. ASD 2. Aortic Stenosis 3. Hypertension 4. Hypertrophic cardiomyopathy 5. Tricuspid regurgitation

23 44 year old with chronic renal failure on hemodialysis. Mild SOB. ECG obtained Q. The most likely explanation; 1. Elevated CK 2. STEMI 3. Fluid overload 4. Hyperkalemia 5. Hypernatremia

24 25 year old female with plueritic chest pain. Troponin is 400 Q. The ECG is diagnostic of; 1. STEMI 2. NSTEMI 3. PE 4. Myopericarditis 5. Aortic dissection

25 Q. This ECG from an 18 year old male shows all of the following, except; 1. Normal variant early repolarization pattern 2. Physiologic sinus arrhythmia 3. Normal AV conduction 4. Left axis deviation 5. Transition zone in lead V3

26 Note the ST depression and T-wave inversion in leads V 2 -V 6. Non-ST Elevation Infarction Here s an ECG of an evolving non-st elevation MI: Question: What area of the heart is infarcting? Anterolateral

27 Case 3; The ECG is from a 64 year old Caucasian male referred by the primary care physician to the cardiac outpatient clinic because of a very abnormal ECG. The patient is asymptomatic, without any sort of chest pain, dyspnea, palpitations, or previous syncope or dizzy spells. The BP is 130/80 mmhg and there are not murmurs on auscultation.

28 Q. What would you do?; 1. Urgent hospital admission for coronary arteriography 2. Urgent angiographic CT scan to exclude pulmonary embolism 3. Consider this ECG as a normal variant and reassure the patient accordingly 4. Nothing, this is a typical artifact originating from a poor connection of the Wilson terminal to the ground 5.None of the above

29 ECGs similar to this one can be seen in: 1. Athletes of African or Afro-American origin without the phenotype of hypertrophic cardiomyopathy: our patient is Caucasian and is not an athlete, but a 64 year old male in whom his primary care physician obtained a routine ECG 2. Severe hypertensive heart disease: the blood pressure in this patient was normal 3. Valvular aortic stenosis: there were no heart murmurs on auscultation 4. Hypertrophic cardiomyopathy: the absence of murmurs should prompt us to consider a non-obstructive hypertrophic cardiomyopathy

30 cmr

31 Case 4; The ECG is from a 53 year old male with a history of high blood pressure for the last couple of years. He is overweight and has mild hyperglycemia. He is referred by the primary care physician to the cardiac outpatient clinic because of a history of episodes of palpitations during the last 3 months, unrelated to exercise, of a very short duration, two or 3 times per month. On auscultation there is a 2/6 systolic murmur along the left sternal border and a wide splitting of the second heart sound.

32 Q. What would you do first?; 1.Chest X ray 2.2D ECHO 3.Holter recording 4.CT scan 5.Cardiac MRI

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35 THANK YOU