ECG Cases ECG Case 1 Springer International Publishing AG, part of Springer Nature 2018 S. Okutucu, A. Oto, Interpreting ECGs in Clinical Practice, In Clinical Practice, https://doi.org/10.1007/978-3-319-90557-0 99
100 ECG Case 2 ECG Case 3
101 ECG Case 4 ECG Case 5
102 ECG Case 6 ECG Case 7
103 ECG Case 8 ECG Case 9
104 ECG Case 10 ECG Case 11
105 ECG Case 12 ECG Case 13
106 ECG Case 14 ECG Case 15
107 ECG Case 16 ECG Case 17
108 ECG Case 18 ECG Case 19
109 ECG Case 20 Please find the correct statements in following answer pages after ECG cases. Answers for ECG Cases ECG case Main ECG findings Diagnosis 1 Sinus rhythm, 60 bpm Q waves in II, III, avf, Q waves in V3 V6 Cardiac axis is 45 Old inferior wall myocardial infarction Old anterior wall myocardial infarction Left axis deviation 2 Short PR interval QRS duration is 135 ms, delta waves 3 Sinus rhythm, 55 bpm Q waves in III and avf Cardiac axis is 30 Pre-excitation Sinus bradycardia Old inferior wall myocardial infarction Borderline left axis deviation
110 ECG case Main ECG findings Diagnosis 4 Sinus rhythm, 60 bpm Premature second beat with negative P wave in II and normal QRS width Cardiac axis is 90 5 No visible P waves ST segment elevation in V1 V6, I and avl Reciprocal ST segment depression in II, III and avf Premature fifth and ninth beats with wide QRS 6 Sinus rhythm, alternating normal QRS beats with positive P wave in II and premature beats with wide QRS 7 Narrow QRS tachycardia with a heart rate of 240 bpm Termination of tachycardia (shown with arrow) Short PR interval and Delta waves (shown with *) 8 Sinus rhythm, 105 bpm, widespread ST segment depression and T wave inversions except in avr 9 Sinus rhythm, 80 bpm Premature beats with altered P waves in every fourth beat 10 Sinus rhythm, 60 bpm Sinus arrest (shown with arrow) Second degree atriventricular block (Mobitz Type II, shown with *) Inverted T waves in V4 V6 Sinus rhythm Premature atrial contraction Borderline right axis deviation Atrial fibrillation Acute extensive anterior wall myocardial infarction Premature ventricular contractions Sinus rhythm, premature ventricular contractions following rule of bigeminy Supraventricular tachycardia Pre-excitation Sinus tachycardia, subendocardial injury, subepicardial ischemia Sinus rhythm, Premature atrial contractions following rule of quadrigeminy Sinus rhythm, sinus arrest and atrioventricular block following carotid sinus message
111 ECG case Main ECG findings Diagnosis 11 Sinus rhythm, 65 bpm, QRS duration 120 ms Presence of RSR in left precordial leads, absence of q waves in I, V4 V6; absence of initial r wave in V1 QRS discordant ST segment and T waves 12 Sinus rhythm, 80 bpm, prolonged PR interval Tall R wave in avl P mitrale Cardiac axis is 45 13 Sinus rhythm, 75 bpm Hyperacute T waves and ST segment elevation in V1 V4 14 Sinus rhythm, 75 bpm ST segment elevation in V2 V6, I and avl Alternating narrow QRS beats with positive P wave in II and premature wide QRS 15 Sinus rhythm, 90 bpm ST segment elevation in V4 V6 De Winter s T waves in V2, V3 16 No visible P waves with irregular RR intervals Average heart rate is around 200 bpm Delta waves with wide QRS complexes Left bundle branch block First degree AV block Left ventricular hypertrophy Left atrial enlargement Left anterior hemiblock Sinus rhythm Acute anterior wall myocardial infarction Sinus rhythm, acute extensive anterior wall myocardial infarction Premature ventricular contractions following rule of bigeminy Sinus rhythm Acute anterior wall myocardial infarction Pre-excited atrial fibrillation
112 ECG case Main ECG findings Diagnosis 17 Polymorphic ventricular tachycardia, Rapid, irregular QRS complexes, which appear to be twisting around the ECG baseline 18 Sinus rhythm, 105 bpm Widespread concave ST-segment elevation ST-segment depressions in leads avr and V1 Depression of the PR segment Spodick s Sign (downsloping of the TP line) 19 Sinus rhythm, 75 bpm ST segment elevation in II, III and avf ST segment depression and prominent R waves in V1 V3 20 Saw tooth pattern of flutter waves in leads II, III, avf Ventricular rate is fixed and 70 bpm Tall R wave in avl Torsades de Pointes Sinus tachycardia Acute pericarditis Sinus rhythm Acute inferoposterior wall myocardial infarction Atrial flutter Left ventricular hypertrophy
Index A Accelerated idioventricular rhythm (AIVR), 25, 26 Accelerated junctional rhythm (AJR), 24 26 Acute anterior wall myocardial infarction, 69 Acute anteroseptal wall myocardial infarction, 70 Acute extensive anterior wall myocardial infarction, 70 Acute inferior myocardial infarction, 74 Acute inferoposterior wall myocardial infarction, 72 Acute lateral myocardial infarction, 74 Acute myocardial infarction, 68, 77, 78 Acute pericarditis, 80 88, 90 early repolarization, 80 ECG stages, 79 electrolyte abnormalities and drug effects digitalis effect, 83, 84 ECG changes, 81 electromagnetic interference artifact, 88 hyperkalemia, 80, 81 hypokalemia, 82 hypothermia, 88 long QT, 85 87 motion artifact, 90 QTc interval, 84, 85 stroke, 88 wandering baseline artifact, 88 vs. myocardial infarction, 78 PR-segment elevation, 77 ST-segment depression, 77 ST-segment elevation, 77 79 Arrhythmogenic right ventricular dysplasia/ cardiomyopathy (ARVD/ARVC), 94 Ashman beats, see Ashman phenomenon Ashman s phenomenon, 92 Asystole, 85 Atrial fibrillation (AF), 35, 36 Atrial flutter, 33 35 Atrial premature beats (APB), see Premature atrial contractions (PACs) Atrial premature complexes (APC), see Premature atrial contractions (PACs) Springer International Publishing AG, part of Springer Nature 2018 S. Okutucu, A. Oto, Interpreting ECGs in Clinical Practice, In Clinical Practice, https://doi.org/10.1007/978-3-319-90557-0 113
114 Index Atrial tachycardia (AT), 30 Atrioventricular nodal reentrant tachycardia (AVNRT), 31, 32, 34 Atrioventricular reentrant tachycardia (AVRT), 31, 33 B Bazett s formula, 15 Biatrial enlargement, 57 Brugada sign, 91 Brugada syndrome, 91, 92 Bundle branch block, 51 53 C Cardiac chamber enlargement, 59, 60 biatrial enlargement, 57 left atrial enlargement, 57 low voltage, 62, 63 LVH chest leads, 60 Cornell voltage criteria, 60 extremity leads, 60 pressure overload, 59 sinus rhythm, 59, 60 Sokolow-Lyon index, 60 volume overload, 59 right atrial enlargement, 57 RVH, 61 Cardiac conduction system bundle branch block, 51 53 components, 45 first degree AV block, 47, 48 heart block, 46 left anterior fascicular block, 51, 54 left posterior fascicular block, 51, 55 manifestation, 46 second degree AV block, 48, 49 sino-atrial (SA) exit block, 46, 47 sinus arrest, 46 third-degree AV block, 49, 50 Wenckebach Phenomenon, 48 Cardiomyocytes, 67 Clockwise rotation, 13 Complete heart block, see Third-degree atrioventricular (AV) block Cornell voltage criteria, 60 Coronary artery disease, 68 75 infarct-related artery, 69 myocardial infarction acute anterior wall, 69 acute anteroseptal wall, 70 acute extensive anterior wall, 70 acute inferior, 74 acute inferoposterior wall, 72 acute lateral, 74 acute MI, 68 localization, 75 old anterior wall, 71 old inferior wall, 73 pathologic Q waves, 68 ST segment elevations, 68, 72 subacute anterior wall, 71 subacute inferior wall, 73 myocardial ischemia, 66 spectrum, 65 ST segment depression, 67 T wave inversions, 67 Corrected QT interval (QTc interval), 15, 84 Counterclockwise rotation, 13 Crochetage sign, 91, 93 D Delta wave, 37 de Winter ECG pattern, 92 De Winter s T waves, 92, 93 Digitalis effect, 83, 84
Index 115 E Einthoven s triangle, 3 Electrocardiography (ECG), 4, 5, 7 axis deviation, 16, 17 basic intervals, 9 Bazett s formula, 15, 16 chest (precordial) leads anatomic relations, with horizontal cardiac section, 7 localization, 5 and orientation with cardiac horizontal axis, 4, 5 definition, 1 ECG waves, 9, 12 Einthoven s triangle, 3 electrical signal, 2 heart rate calculation, 17, 18 12-lead ECG displays, 7, 8 limb leads, 6 localization, 4 normal heart axis, 16, 17 paper speed, 1 points and segments, 9 posterior chest leads, 7 PR interval, 10, 11 PR segment, 10, 11 QRS complex, 11, 12, 14 QT interval, 15, 16 QTc interval, 15, 16 right-sided precordial leads, 7 ST segment, 14 standard extremity leads, 4 three standard bipolar leads, 3 tracings, 2 transitional zone, 13 unipolar leads, 3 ventricular depolarization, 11 14 Electromagnetic interference (EMI) artifact, 88, 89 Eponymous ECGs Ashman s phenomenon, 91, 92 Brugada syndrome, 91, 92 Crochetage sign, 91, 93 de Winter ECG pattern, 92 de Winter s T waves, 92, 93 Epsilon wave, 94, 95 McGinn-White sign, 94, 95 Spodick's sign, 95, 96 Wellens syndrome, 92, 94 Epsilon wave, 94, 95 F Fascicle, 45 Fatal ventricular fibrillation, 85 First degree atrioventricular block, 47, 48 H Hypercalcemia, 82 Hyperkalemia, 80, 81 Hypocalcemia, 82 Hypokalemia, 82 Hypomagnesemia, 82 Hypothermia, 88 L Large negative wave, see S-wave Left anterior fascicular block, 51, 54 Left atrial enlargement, 57 Left posterior fascicular block, 51, 55 Left ventricular hypertrophy (LVH) chest leads, 60 Cornell voltage criteria, 60 extremity leads, 60 pressure overload, 59 sinus rhythm, 59, 60 Sokolow-Lyon index, 60 volume overload, 59 Limb leads, 6 Low voltage, 62, 63
116 Index M McGinn-White sign, 94, 95 Mobitz type I, 46, 48 Mobitz type II, 46, 49 Motion artifact, 89, 90 Multifocal atrial tachycardia (MAT), 30, 31 Myocardial infarction (MI) acute anterior wall, 69 acute extensive anterior wall, 70 acute inferior, 74 acute inferoposterior wall, 72 acute lateral, 74 acute MI, 68 localization, 69, 75 old anterior wall, 71 old inferior wall, 73 pathologic Q waves, 68 vs. pericarditis, 78 ST segment elevations, 68, 72 subacute anterior wall, 71 subacute inferior wall, 73 Myocardial injury, 67 Myocardial ischemia, 66 N Normal cardiac rhythm cardiac impulse formation, 20 conduction systems, 19, 20 nodal, 19 normal sinus rhythm, 21 sinus bradycardia, 22 sinus tachycardia, 23 Non-respiratory sinus arrhythmia, 24 Normal sinus rhythm (NSR), 21 P Pacemaker rhythm, 40 42 Premature atrial contractions (PACs), 27, 28 Premature ventricular complex, see Premature ventricular contraction (PVC) Premature ventricular contraction (PVC), 27 29 Pulmonary embolism, 94 P waves, 9 10, 20, 23 Q QRS complex, 11, 12 QT interval, 15 Q-wave, 9, 11, 13, 14 R R-bis wave (R ), 11 Right atrial enlargement, 57 Right ventricular hypertrophy, 61 R-prime wave, 11 R-wave, 9, 11, 13 S Second degree atrioventricular block, 48, 49 Short PR interval, 35, 37, 38 Sick sinus syndrome (SSS), 47 Sino-atrial (SA) exit block, 46, 47 Sinus arrest, 46 Sinus arrhythmia, 23, 24 Sinus bradycardia, 22 Sinus nodal reentrant tachycardia (SNRT), 31 Sinus tachycardia, 23 Small negative wave, see Q-wave Small positive wave, see R-wave Sodium channelopathy, 91 Sokolow-Lyon index, 60 Spodick s sign, 95, 96 S1Q3T3 pattern, 94 Standard extremity leads, 4 Stroke, 88 ST segment depression, 67 Subacute anterior wall myocardial infarction, 71 Subacute inferior wall myocardial infarction, 73 Subendocardial ischemia, 65, 67
Index 117 Supraventricular tachycardia (SVT), 30 S-wave, 9, 13 T Tachyarrhythmias SVT, 30 34 VT, 30 Third-degree atrioventricular (AV) block, 49, 50 Third-degree heart block, see Third-degree atrioventricular (AV) block Three standard bipolar leads, 3 Transitional zone, 13 T wave, 9, 15 Type II (Mobitz), 46 Ventricular fibrillation (VF), 40 Ventricular free walls, 13 Ventricular premature beat (VPB), see Premature ventricular contraction (PVC) Ventricular premature contraction (or complex or complexes) (VPC), see Premature ventricular contraction (PVC) Ventricular septum, 11 Ventricular tachycardia (VT), 30, 37, 39 Ventriculophasic sinus arrhythmia, 24 U Unipolar chest (precordial) leads, 4 U wave, 15 V Ventricular depolarization, 11 14 Ventricular extrasystole (VES), see Premature ventricular contraction (PVC) W Wandering baseline artifact, 88, 89 Wellens syndrome, 92 94 Wenckebach pattern, 47 Wenckebach Phenomenon, 47, 48 Wolff-Parkinson-White Syndrome (WPW), 31, 35