SA HEART 2018 PRE-CONGRESS WORKSHOP 4 OCTOBER 2018 ECG Interactive Session Ashley Chin Cardiologist/Electrophysiologist University of Cape Town Groote Schuur Hospital
ECG 1
Which ONE of the following is the best ECG diagnosis? a) Mobitz I AV block b) Mobitz II AV block c) 2:1 AV block d) Complete heart block
Which ONE of the following is the best ECG diagnosis? a) Mobitz I AV block b) Mobitz II AV block c) 2:1 AV bloc d) Complete heart block 3 criteria to diagnose CHB 1. P>QRS complexes 2. Escape rhythm = regular 3. No relationship between P and QRS complexes
Complete heart block is a medical emergency and patients should be referred for urgent pacing Mechanisms of death with CHB: 1. Pause-dependent Torsades de Pointes 2. Asystole (ventricular escape rhythm fails)
ECG 2
You are called to the casualty department for a request for urgent pacing. What is the diagnosis? a) Complete heart bock b) Mobitz I AV block c) Mobitz II AV block d) Sinus node dysfunction with isorhythmic AV dissociation
You are called to the casualty department for a request for urgent pacing. What is the diagnosis? a) Complete heart bock b) Mobitz I AV block c) Mobitz II AV block d) Sinus node dysfunction with isorthythmic AV dissociation 3 criteria to diagnose CHB 1. P>QRS complexes (NO) 2. Escape rhythm = regular (YES) 3. No relationship between P and QRS complexes (YES) AV dissociation is present, but no P wave that should have conducted, does not conduct
ECG 3
Which ONE of the following is the best ECG diagnosis? a. 2:1 AV block with RBBB and LAHB b. 1 st degree AV block with RBBB and LAHB c. Trifascicular block d. Mobitz II AV block
Which ONE of the following is the best ECG diagnosis? a. 2:1 AV block with RBBB and LAHB b. 1 st degree AV block with RBBB and LAHB c. Trifascicular block d. Mobitz II AV block
Non-conducted P waves very easily missed! Look for non-conducted P waves in any bradycardia especially if QRS is wide Look for high frequency deflection in the T wave
ECG 4
Which ONE of the following is the best ECG diagnosis? a. Typical atrial flutter b. Sinus tachycardia c. AV nodal re-entry tachycardia d. Atrial tachycardia
Which ONE of the following is the best ECG diagnosis? a. b. c. d. Typical atrial flutter Sinus tachycardia AV nodal re-entry tachycardia Atrial tachycardia
Typical Atrial flutter =>>counter clockwise cavotricuspid isthmus dependent flutter Flutter waves (240-360bpm) 2:1 AV block (usually 150bpm) Negative flutter waves II, III, AVF Positive flutter waves in V1 NEJM 2012;367;1438
TACHYARRHYTHMIAS Regular Narrow QRS Narrow QRS Irregular Sinus tachycardia Atrial flutter AVJRT (AVNRT, AVRT) Atrial tachycardia Junctional ectopic tachycardia Atrial Fibrillation Atrial flutter/tachy + variable AVB Multifocal atrial tachycardia VT SVT with BBB Paced rhythm Antidromic AVRT Pre-excited SVT AF with BBB A flutter, variable AVB + BBB Preexcited AF Polymorphic VT Regular W I D E QRS W I D E QRS Irregular
Flutter waves may be hidden in the QRS complexes and may be difficult to see Suspect if wavy baseline suggesting continuous atrial activity Suspect in patients with structural heart disease especially with ventricular rates (120bpm- 180bpm)
Carotid massage unmasks flutter waves by inducing AV block
ECG 5
Which ONE of the following is the best ECG diagnosis? a. Ventricular tachycardia b. Supraventricular tachycardia with RBBB c. Pacemaker tachycardia d. Pre-excited tachycardia
RBBB Typical patterns of right & left bundle branch block LBBB V1 rsr in V1 Broad terminal R in V1 V1 & V2 negative V5 & V6 positive Initial sharp deflection V1 & V2 (< 40 ms) V6 V6 Normal left ventricular activation (septal q, rapid R upstroke in V6) Slurred R wave Absent septal q wave Small, broad terminal s in V6 Inverted T wave AO MEMORIAL ADVANCED ECG & ARRHYTHMIA COURSE
RBBB V1 V6 Which ONE of the following is the best ECG diagnosis? a. Ventricular tachycardia b. Supraventricular tachycardia with RBBB c. Pacemaker tachycardia d. Pre-excited tachycardia
Which ONE of the following is the best ECG diagnosis? a. Ventricular tachycardia b. Atrial flutter 2:1 with RBBB c. Pacemaker tachycardia d. Pre-excited tachycardia
Note sinus rhythm ECG with RBBB, but remember that BBB can be rate related
ECG 6
Which ONE of the following is the best ECG diagnosis? a. Ventricular fibrillation b. Torsade de Pointes c. Pre-excited atrial fibrillation d. Artefact
Which ONE of the following is the best ECG diagnosis? a. b. c. d. Ventricular fibrillation Torsade de Pointes Pre-excited atrial fibrillation Artefact
Normal calibration = 10mm/mV Very large voltages = artefact
DONALD J TRUMP
Ventricular fibrillation
Acute Anterior/Septal STEMI
Non-sustained polymorphic VT
ECG 7
Which ONE of the following is the best ECG diagnosis? a. Acute antero-septal myocardial infarction b. Brugada pattern c. Early repolarization syndrome d. Acute pulmonary embolism
Acute STEMI Which ONE of the following is the best ECG diagnosis? a. Acute antero-septal myocardial infarction b. Brugada pattern c. Early repolarization syndrome d. Acute pulmonary embolism
ECG 8
BLOEMFONTEIN ECG COURSE Which ONE of the following is the best ECG diagnosis? a. Atrial fibrillation with RBBB b. Pre-excited atrial fibrillation c. Atrial flutter with variable block with RBBB d. Polymorphic ventricular tachycardia
BLOEMFONTEIN ECG COURSE Which ONE of the following is the best ECG diagnosis? a. Atrial fibrillation with RBBB b. Pre-excited atrial fibrillation c. Atrial flutter with variable block with RBBB d. Polymorphic ventricular tachycardia
BLOEMFONTEIN ECG COURSE What is the next step in management? a. DC cardioversion b. IVI amiodarone c. IVI adenosine d. IVI verapamil
BLOEMFONTEIN ECG COURSE What is the next step in management? a. DC cardioversion b. IVI amiodarone c. IVI adenosine d. IVI verapamil
SA Heart Journal Quarterly ECG Quizes http://www.journals.ac.za/index.php/sahj