Unknown ECGs for the Clinician

Transcription

1 Unknown ECGs for the Clinician 2016 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 89 year old male presents with syncope and briefly regains consciousness in the ER only to pass out once the telemetry patches are applied A. You would immediately shock this rhythm B. Recommend emergency temporary pacemaker You would immediately shock th.. Recommend emergency tempora.. 1

2 89 year old male presents with syncope and briefly regains consciousness in the ER only to pass out once the telemetry patches are applied After a few seconds the patient briefly regains consciousness and then has a seizure and the following ECG is obtained. At this point you would: A. Shock the patient B. Call for temporary pacemaker placement Shock the patient Call for temporary pacemaker... After a few seconds the patient briefly regains consciousness and then has a seizure and the following ECG is obtained. At this point you would: 2

3 A temporary pacemaker is placed. Further history is obtained that the patient has been in chronic atrial flutter for years and refused ablation. He is on no oral AV nodal blockers and only takes eye drops for glaucoma At this point you would: A. Recommend a permanent dual chamber DDD pacemaker B. Recommend a single chamber VVI pacemaker C. Ask about his eye drops Recommend a permanent dual... Recommend a single chamber V.. Ask about his eye drops Patient admits to using Timololeye drops for his glaucoma. He is placed on a non beta blocker eye med but significant bradycardia persists, he agrees to pacemaker implantation at this point. A leadless ventricular pacemaker is placed. 3

4 10 The following rhythm is from a 76 year old male who presents with a transient left hemiparesis: He has a history of HTN, DM and was hospitalized six months ago with fluid on the lungs. He notes pain in his left leg if he walks a block or more. This Rhythm is: A. Atrial fibrillation B. Atrial Flutter C. It doesn t matter because they will both be treated the same way Atrial fibrillation Atrial Flutter It doesn t matter because they w... 4

5 He has a history of HTN, DM and was hospitalized six months ago with fluid on the lungs. He notes pain in his left leg if he walks a block or more. He is placed on amiodarone and a NOAC and undergoes a TEE which shows no LAA clot and is cardioverted to NSR only to return three weeks later with A-fib with complaints of dyspnea and poor exercise tolerance He agrees to undergo pulmonary vein isolation procedure The procedure is performed and is successful with restoration of NSR and the patient feels great He can be taken off his anticoagulation: A. In 4 weeks B. In 12 weeks C. Never In 4 weeks In 12 weeks Never 5

6 CHADS VASC 2 CHF HTN Age DM Stroke/TIA VASC Dz Predicts Inflammation Predicts Stroke A-fib Most high CHADS2 patients who present with stroke have had at least one episode of Afib within 30 days prior to presentation A. True B. False True False This patient: A. Should be immediately defibrillated B. Has clean teeth C. Should be sent to the neurologist Should be immediately defibri... Has clean teeth Should be sent to the neurologist 6

7 A 48 year old male presents to the ER with light headedness and the following ECG This rhythm is : A. Vtach B. SVT Vtach SVT A 48 year old male presents to the ER with light headedness and the following ECG This rhythm is : 7

8 As you prepare to shock the ECG changes to this: What is the rhythm now? A. Sinus tach with spontaneous resolution of the Vtach B. Atrial flutter C. Vtach Sinus tach with spontaneous res... Atrial flutter Vtach As you prepare to shock the ECG changes to this: 56 year old male with several episodes of vertigo, he has been taking his wife's Antivert without symptom relief: The following is true: A. He has prolonged QT syndrome B. He has true vertigo and the ECG strip shows artifact C. He is at high risk for sudden cardiac death D. An ablation will be unlikely to help He has prolonged QT syndrome He is at high risk for sudden card... He has true vertigo and the ECG s... An ablation will be unlikely to help 8

9 56 year old male with several episodes of vertigo, he has been taking his wife's Antivert without symptom relief: Cardiac catheterization shows clean coronaries and an EF of 45%, the next step is: A. Start beta blockers and ACE inhibitors and reevaluate in three months for ICD B. Start beta blockers, ACE inhibitor, give patient a defibrillator vest and reevaluate in three months for ICD C. Implant ICD and start amiodarone D. Ablate Start beta blockers and ACE inhi... Start beta blockers, ACE inhibitor... Implant ICD and start amiodarone Ablate Cardiac catheterization shows clean coronaries and an EF of 45%, the next step is: 9

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11 A 23 year old female who speaks only Karen presents to the emergency room with palpitations, SOB, and extreme light headedness She collapses almost immediately on arrival and is shocked for the following rhythm: She regains consciousness and via interpreter the following additional information is obtained: She has had some vague chest pain and nausea for about four weeks and makes herself vomit which seems to help She has never passed out or felt palpations before She is eight weeks pregnant The following ECG is then obtained following the external defib shock: 11

12 You would then: A. Take her to the cath lab because of suspected right coronary dissection causing an inferior infarction (which has a higher incidence during pregnancy) the presenting rhythm was Vtach B. Take her to the electrophysiology lab for ablation the presenting rhythm was Atrial fibrillation C. Start Sotolol Take her to the cath lab because.. Take her to the electrophysiolo.. Start Sotolol This patient: A. Is having an MI B. Has an idioventricular rhythm C. Is about to have a cardiac arrest. D. Has atrial fibrillation and is having an MI and is about to have a cardiac arrest Is having an MI Has an idioventricular rhythm Is about to have a cardiac arrest. Has atrial fibrillation and is hav... 12

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14 Patients with this problem can have torsade: A. During sleep B. While swimming C. During scary movies D. All of the above During sleep While swimming During scary movies All of the above 14

15 Causes of QT prolongation 1. Congenital ion channelopathies 2. Drugs Acquired channelopathies 3. Electrolyte abnormalities The following ECG shows: A. Obvious pacemaker malfunction B. Proper pacemaker function Obvious pacemaker malfunction Proper pacemaker function 15

16 73 year old male had BiV ICD implanted for primary prevention SCD He has had no shocks for three years Recently he began going to Walmart to help his wife carry groceries. For the past three weeks he has received a single shock while waiting in Walmart for her to complete her errands. He should: A. Seek immediate medical attention B. Be evaluated for a lead fracture C. Stop going to Walmart Seek immediate medical attention Be evaluated for a lead fracture Stop going to Walmart 16

17 This patient has: A. Ventricular Tachycardia B. An Acute MI C. Bundle Branch Block D. Coronary Spasm Ventricular Tachycardia An Acute MI Bundle Branch Block Coronary Spasm If the patient: A. Develops Atrial fibrillation give Sotololand then cardiovert B. Develops pneumonia give erythromycin C. Develops a fungal infection give Ketaconozole D. Develops depression give Elavil E. None of the above Develops pneumonia give eryt... Develops Atrial fibrillation give... Develops depression give Elavil Develops a fungal infection give... None of the above 17

18 Asystole 18