10/22/2015
12-Lead EKG Interpretation [email protected]
Jon Tardiff, BS, PA-C OHSU Clinical Assistant Professor
Disclosures:
• I work for Virginia Garcia Memorial Health Center, Beaverton, Oregon.
• And I am a medical editor for Jones & Bartlett Publishing.
11 clinics: 39,000 patients from all over the World!
Arabic, Somali, Mai Mai, Pashtu, Urdu, ASL, and more!
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Goals for today’s ECG Review:
• Determine Right vs Left bundle branch blocks • Determine Axis • Diagnose Acute MI • Diagnose old MI • Location of the infarct • Other Acute Coronary Syndromes • Life Threatening Syndromes
“Ask questions!” ☺☺☺
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Ready?
What a 12-Lead EKG can help you do
• Diagnose ACS / AMI • Interpret arrhythmias (computer Dx) • Identify life-threatening syndromes (WPW, LGL, Long QT synd., Wellens synd., etc) • Infer electrolyte imbalances • Infer hypertrophy of any chamber • Infer COPD, pericarditis, drug effects, and more!
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For example: 73 y.o. male with nausea, syncope
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Acute Inferior MI
ST elevation
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What rhythm? (look at V1 for P waves)
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Atrial flutter (w/septal MI?)
The flutter waves are invisible in Lead II
another example…
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WPW with Atrial Fib
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Wolff-Parkinson-WhiteWPW Graphic synd.
• short PR • wide QRS • delta wave
Same pt, converted to SR
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Limitations of a 12-Lead ECG
• Truly useful only ~40% of the time • Each ECG is only a 10 sec. snapshot • Serial ECGs are necessary, especially for ACS • Other labs help corroborate ECG findings (cardiac markers, Cx X-ray) • Confounders must be ruled out (dissecting aneurysm, pericarditis, WPW, LBBB, digoxin, RVH)
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Confounder: Left Bundle Branch Block
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Limitations of a 12-Lead ECG
• The ECG is occasionally wrong!
Impending AMI with normal ECG!
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13 hrs later — Acute Anterior MI
Elevated ST segments
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Confounder: Wolff-Parkinson-White syndrome
Pt is a 4 y.o. child w/ one episode of tachycardia and shortness of breath. WPW mimicking MI ( false Q waves in Lead II, III, AVF, V1, & V3). Also mimicking LBBB.
“ECG Pearls” • Lead II is the easiest lead to read / most intuitive • But Lead V1 is our single best lead. • Use Lead V3 for QT interval measurement • “A Q in III is free.” (isolated Q in Lead III) • Half of reading an ECG is knowing where the + electrode is. • The other 80% is: finding the P wave! ☺
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ECG Lead Placement & Electrophysiology Review
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Einthoven’s Triangle
Limb Leads
I (standard II leads) III
- ±
23 +
Leads I, II, III
I
II III
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Normal 12-Lead ECG
The first EKG machine ca 1903
Rapid Interpretation Tips
Dr. Willem Einthoven
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Dr. Willem Einthoven
• Invented the electrocardiograph • Discovered atrial fibrillation • Won Nobel Prize for Medicine 1924
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Conduction System
II R T P U
Q S
SA Node AV Node His Bundle BBs Purkinje Fibers 2828
Lead II
P wave axis …upright in L II
R
R wave axis …upright in L II
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QRS Morphology in Lead II
II
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Intervals II
PR
QRS QT
PR Interval: 120 – 200 mSec (3 – 5 boxes) QRS width: 60 – 120 mSec (1½ – 3 boxes) QT/QTc interval: 400 mSec (10 boxes) 3131
Heart Rate Calculations Triplicate Method: 6-second : 300, 150, 100, Count PQRST in a 6- 75, 60, 50 second strip & multiply x 10 Quick, easy, sufficient Easy, & more accurate
300 150 100 75 60 6 seconds
Horizontal axis is time (mS); vertical axis is electrical energy 32(mV)
Normal Sinus Rhythm
6 seconds
What is the heart rate?
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EKG Leads
Limb (frontal plane) Leads
I (standard II leads) III aVR aVL (augmented leads) aVF
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Normal 12-Lead ECG
6 Frontal Plane Leads (limb leads)
I
II III
L
R F
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Axis Leads - I II III aVR * aVL aVF
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“Knowing where the + electrode is”
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EKG Leads
Limb (frontal Chest (precordial) plane) Leads Leads I V1 (standard (anterior II leads) V2 III V3 leads) aVR V4 aVL V5 (lateral aVF V6 leads)
(augmented leads) 39
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V Lead Cutaway
V Lead Progression
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Normal 12-Lead ECG
Lots of ways to read EKGs…
• QRSs wide or narrow? • Sinus rhythm or not? • Regular or irregular? • If not, is it atrial fibrillation? • Fast or slow? • BBB? • P waves? • MI?
Symptoms: • Syncope is bradycardia, heart blocks, or VT • Rapid heart beat is AF, SVT, or VT
Step-by-step method for reading a 12-Lead
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Rapid Interpretation Tips • Identify the rhythm.Rapid IfInterpretation supraventricular* Tips , If no LBBB,
If present, • Rule out other confounders: WPW, pericarditis, LVH, digoxin effect • Identify location of infarct, and consider appropriate treatments: MONA, PCI [or fibrinolytic], nitrate infusion, heparin infusion, GP IIb, IIIa inhibitor, beta- blocker, clopidogrel, statin, etc.
Supraventricular rhythms
• Sinus rhythm • Atrial fibrillation • Junctional rhythm • PSVT / AVNRT (AV nodal re-entry tachycardia) • Atrial tachycardia • Atrial flutter • Wandering atrial pacemaker • MAT
Normal 12-Lead ECG
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Rapid Interpretation Tips • Identify the rhythm.Rapid IfInterpretation supraventricular, Tips If no LBBB,
If present, • Rule out other confounders: WPW, pericarditis, LVH, digoxin effect • Identify location of infarct, and consider appropriate treatments: MONA, PCI [or fibrinolytic], nitrate infusion, heparin infusion, GP IIb, IIIa inhibitor, beta- blocker, clopidogrel, statin, etc.
The Problem with Bundle Branch Blocks
• Desynchronized contraction of the ventricles • Reduced cardiac output • Worsened heart failure • LBBB confounds the EKG interpretation and makes it harder to find ACS
Bundle Branch Blocks (QRS > 0.12 sec.)
(right-sided lead) (left-sided lead)
V1 R’ I notch r
S Left BBB Right BBB (L I, V5, V6: (V1, V2, MCL1: upright QRS rsR’ pattern) with a notch)
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Bundle Branch Blocks: Two QRSs
Blocked Healthy bundle ventricle
V1 R’ I notch I slur r
S 52
RBBB
V1 & V 2
LBBB
V5 V6 (& I, aVL)
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Practice: Bundle Branch Block
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Which Bundle Branch is Blocked? 1
RBBB
Right Bundle Branch Block (Lead V1) 1
RBBB
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Which Bundle Branch is Blocked? 2 LBBB 12-Lead
2 LeftLBBB Bundle 12-Lead Branch Block (L I, V5, V6)
Where is the Pathology?
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Right Bundle Branch Block
Where is the Pathology?
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Left Bundle Branch Block
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Axis Determination
Why We Care About Axis Deviations
The axis shifts towards hypertrophy & away from infarction
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Axis Deviation
Horizontal heart (0 °): obesity, 3rd trimester pregnancy. Ascites
Vertical heart (90 °): slender build
Left Axis Deviation : LBBB, Anterior MI, Inferior MI, Left anterior hemiblock, LVH
Right Axis Deviation : Anterior Normal axis = -20 ° to +110 ° MI, Lateral MI, RBBB, COPD, RVH, Left posterior hemiblock
Extreme RAD : Ectopic rhythm (VT), massive MI 66
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How to calculate Axis
Easiest: the computer does it for you!
Easy : find the tallest R wave (if tallest is Lead II = normal axis )
Even easier : (if Lead II is upright = normal axis
Funnest : Thumbs up / Thumbs down
Calculating Axis: Thumbs Up / Down Method
Lead I —Your Left thumb Lead aVF —Your Right thumb
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Practice: Axis 3 I
F
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Axis Practice Normal Axis 3
I
F 70
4 I
F
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4 Left Axis Deviation I
F
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5
73
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6
75
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6 Extreme Right Axis Deviation
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New 12-Lead ECG Format
aVL II
I aVF
-aVR III
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New 12-Lead ECG Format New
aVL II
I aVF
Old -aVR III
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Rapid Interpretation Tips • Identify the rhythm.Rapid IfInterpretation supraventricular, Tips • Rule out left bundle branch block. If no LBBB, • Check for: ST elevation, or ST depression with T wave inversion, and/or pathologic Q waves . If present, • Rule out other confounders: WPW, pericarditis, LVH, digoxin effect • Identify location of infarct, and consider appropriate treatments: MONA, PCI [or fibrinolytic], nitrate infusion, heparin infusion, GP IIb, IIIa inhibitor, beta- blocker, clopidogrel, statin, etc.
ST elevation, ST depression, T wave inversion, pathologic Q waves STEMI
Normal Ischemia Injury Infarction
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Percutaneous Coronary Intervention
RCA before and after stenting
Before stenting After stenting
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STEMI: ECG Changes
(normal) (w/onset cx pn) A. Normal ECG B. Hyperacute T wave changes - increased T wave amplitude and width; may also see ST elevation (20 minutes) (1 hour) C. Marked ST elevation with hyperacute T wave changes (transmural injury) D. Pathologic Q waves , less ST
(>1 hr) elevation, terminal T wave (1 week – years) inversion (necrosis) E. Pathologic Q waves, T wave inversion (necrosis and fibrosis) F. Pathologic Q waves, loss of R waves (fibrosis)
MI ECG Patterns
Why Pathologic Q Waves Form
Normal q Pathologic Q
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STEMI — Typical Progression
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Acute Inferior MI
Acute Inferior MI#1 Axis is shifting leftward…
ST elevation
Qs Qs
Same Patient~2 hrs later
Acute Inferior MI #2
New ST elevation
Worsened ST elevation
Qs Qs
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Same Patient 9 days later Acute Inferior MI #3
Permanent left axis deviation
But NO anterior infarct (no Qs)
Permanent Q waves (inferior wall scar)
45% of MIs
Acute Anterior MI Page
40% of MIs
Acute Inferior MI Page
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1/3 of Inferior MIs
Acute R Ventricle MI Page
15% of MIs
Acute Lateral MI Page
Acute Posterior MI Page
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Practice: Infarct Location
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Where is the Pathology? 7 Acute Anterior MI
Acute Anterior MI 7 (ST elevation in V1 - V4)
ST Elevation
What is the R wave axis?
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Where is the Pathology? 8
Acute Inferior MI
Acute Inferior MI 8 Acute(ST Inferior elevation MI in II, III, F)
Where is the Pathology? 9
Acute Inferolateral MI
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9
Acute InferolateralAcute MIInferolateral MI (ST elevation in II, III, F, V5, V6)
Note the axis has not shifted yet, because it is early in the AMI, and there are no loss of R waves yet.
Where is the Pathology? 10
Acute Inferior MI & Right Ventricle MI 10 Acute Inferior & Right Ventricle MI
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Where is the MI? • V1, V2, V3 11 • Large R Waves Large R waves • Depressed STs ST Depression
Normal V1 – V3
Acute Posterior MI • V1, V2, V3 11 • Large R Waves Large R waves • Depressed STs ST Depression
Normal V1 – V3
Time for a Break!
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EKG: Life-Threatening Syndromes [email protected]
Jon Tardiff, BS, PA-C 109 Clinical Assistant Professor
Goals of this session:
Identify: • WPW (Wolff-Parkinson-White) syndrome • LGL (Lown-Ganong-Levine) syndrome • Brugada syndrome • Long QT syndrome • Wellens syndrome
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What a 12-Lead EKG can help you do
• Diagnose ACS / AMI • Interpret arrhythmias • Identify life-threatening syndromes (WPW, LGL, Long QT synd., Wellens’ synd., etc) • Infer electrolyte imbalances • Infer hypertrophy of any chamber • Infer COPD, pericarditis, drug effects, and more!
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Top 10 Causes of Death In USA ~ 2,000,000 deaths / year
Not shown are deaths due to medical errors:
~50,000 – 100,000 / year! *
* if you are < 55 y.o., trauma is your most likely risk!
Pacemaker Lead Reversal in a Dual-Chamber Pacemaker
yikes!
Wolff-Parkinson-White Syndrome
Drs. Wolff, Parkinson, and White c. 1930
• Short PR Interval • Wide QRS • “Delta” wave in some leads • Causes tachycardias • Mimicks MI, BBB • Pt is at-risk for sudden death (“R on T”; atrial fibrillation) • Incidence may be 1/1000
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Wolff-Parkinson-WhiteWPW Graphic syndrome
(Bundle of Kent)
Orthodromic PSVT (normal) conduction
Valsalva
WPW-Adensoine Conversion
Adenosine
NSR Antidromic (retrograde) conduction WPW pattern
Drs. Wolff, Parkinson, & White
Dr. Louis Wolff Dr. Paul Dudley White • Chief of • The “Father of American Electrocardiology Cardiology” • CAD, unstable angina • Helped found the AHA • Vectorcardiology • Promoted low cholesterol • Concert violinist diet, normal body weight, normal BP, exercise, cardiac rehab • Advocate for World Peace
Sir John Parkinson, MD • Founded modern British cardiology • Pioneer in radiocardiology • Beloved Teacher
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AF with WPW WPW—rapid mimicking ventricular VTrate!
• Cardiovert, or Amiodarone
A-Fib with WPW degenerating to V-Fib
Defibrillate!
Pad / Paddle Placement
Synchronized Cardioversion
For conscious V-Tach, and SVT. Synchronized shock delivers energy synchronized to the R wave. For: However, for V-Fib and • pacing unconscious V-Tach, defibrillate • defibrillation instead with unsynchronized • synchronized cardioversion shock.
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Lown-Ganong-Levine syndrome
• A “Short PR Syndrome” • Normal QRS (NOT wide) • No “Delta” wave • Must also have episodes of tachycardia in order to be called LGL syndrome. (Otherwise it’s just a short PR interval.)
Dr. Lown Dr. Ganong Dr. Levine
Lown-Ganong-Levine syndrome • Accessory pathway bypasses AV node—inserts into His bundle • This shortens the PR interval • But the QRS is normal (NOT wide) • and there is No “Delta” wave • May have reciprocating tachycardias James fibers
Short PR
Drs. Lown, Ganong, & Levine
Dr. Bernard Lown Dr. William Ganong Dr. Samuel Levine • Developer of the • Electrophysiologist • Levine Grading Scale for defibrillator • Neuroendocrinologist heart murmurs (I/VI) • Coronary Care Units • Fluid, electrolytes, HTN • “Levine Sign” for ACS • Physicians for Social • Author: Review of Medical • Coronary thrombosis Responsibility Physiology • Nobel Peace Prize • Pernicious anemia • Single payer healthcare • Diagnosed FDR with polio (Mass.) • Always on call! • The Lown Institute
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LGL (48 y.o. F) LGL?
Short PR But QRS is narrow, and NO delta wave
Brugada Syndrome (a “channelopathy”)
Dr. Pedro Brugada
• Sodium channel defect (the QRS is a sodium event) • RBBB on EKG, with ST elevation in V1 - V3 • SUDS (Sudden Unexplained Death Syndrome) • 10% of these patients die / year • ICD is life-saving
Brugada Syndrome
R
QS
• The QRS is a sodium event
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Absolute Relative Refractory Refractory Period Period (vulnerable period)
Polymorphic VT in patients with Brugada Syndrome R on T
“R on T” (a PVC on the T wave) causes VT & sudden death
“R on T” phenomenon (PVC on T wave: precipitating V-Tach)
Torsades de Pointes “R on T” (polymorphic V-Tach)
Ventricular Fibrillation
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Long QT Syndrome
Torsades de pointes (polymorphic V-Tach)
• QTc Interval > 450 ms (>470 ms ) (normal QTc is 400 ms) • Several inherited forms, plus temporary, & iatrogenic causes • Incidence may be 1/5000 • A possible cause for SIDS • Patient is at risk for sudden death from R on T, Torsades de Pointes • Beta blockers are therapeutic, along with limiting physical activity • Implanted cardioverter / defibrillator (ICD) is life-saving
QT Interval
II Long QT RR
QT QT should be <½ the R-R interval
QT/QTc interval: 400 mSec (10 boxes) Or: less than ½ the R-R interval
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Long QT Syndrome (use Lead V 3, or V 4, or the longest QT interval on the 12-Lead)
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Dr. Lóng Qú Ti 龙曲提医生
• Obstetrician • Secret Agent • Supercop • Author: Solving Conflict With Dialog
Jackie Chan 成龙先生
• Martial artist • Actor, Singer • Producer, director • 100 films • Beloved father, husband • Great philanthropist!
Long QT Syndrome
Torsades de pointes (polymorphic V-Tach)
• Patient is at risk for sudden death from R on T, polymorphic VT • Implanted cardioverter / defibrillator (ICD) is life-saving
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ICD Shocking V-Tach
ICD is life- saving for patients with Long QT syndrome
Iatrogenic Long QT
Question: What are the Top 3 causes of arrhythmias?
The “Top 3” Causes of Arrhythmias:
1. Medications 2. Medications 3. Medications
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Meds that prolong the QT interval
Here they are!
Albuterol (salbutamol) Alfuzosin Amantadine Amiodarone Amitriptyline Amphetamine Anagrelide Apomorphine Arformoterol Aripiprazole Arsenic trioxide Artenimol+piperaquine Atazanavir Atomoxetine Azithromycin Bedaquiline Bortezomib 139 Bosutinib
Meds that prolong the QT interval
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Meds that prolong the QT interval
Ephedrine Epinephrine (Adrenaline) Eribulin mesylate Erythromycin Escitalopram Famotidine Felbamate Fingolimod Flecainide Fluconazole Fluoxetine Formoterol Foscarnet Furosemide (Frusemide) Galantamine Gemifloxacin Granisetron Halofantrine Haloperidol Hydrochlorothiazide Hydroxychloroquine Hydroxyzine Ibutilide Iloperidone Imipramine (melipramine) Indapamide Isoproterenol 141 Isradipine Itraconazole
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Meds that prolong the QT interval
Ketoconazole Lapatinib Leuprolide (Leuprorelin) Levalbuterol (levsalbutamol) Levofloxacin Lisdexamfetamine Lithium Metaproterenol Methadone Methamphetamine (methamfetamine) Methylphenidate Metoclopramide Metronidazole Midodrine Mifepristone Mirabegron Mirtazapine Moexipril/HCTZ Moxifloxacin Nelfinavir Nicardipine Nilotinib Norepinephrine (noradrenaline) Norfloxacin Nortriptyline Ofloxacin Olanzapine Ondansetron 142 Oxytocin
Meds that prolong the QT interval
Paliperidone Panobinostat Pantoprazole Paroxetine Pasireotide Pazopanib Pentamidine Perflutren lipid microspheres Phentermine Phenylephrine Phenylpropanolamine Pimozide Posaconazole Procainamide (Oral off US mkt) Promethazine Propofol Pseudoephedrine Quetiapine Quinidine Quinine sulfate Ranolazine Rilpivirine Risperidone Ritonavir Salmeterol Saquinavir Sertraline Sevoflurane 143 Solifenacin
Meds that prolong the QT interval
Tacrolimus Tamoxifen Telaprevir Telavancin Telithromycin Terbutaline Tetrabenazine (Orphan drug in US) Thioridazine Tizanidine Tolterodine Toremifene Torsemide (Torasemide) Trazodone Trimethoprim-Sulfamethoxazole Trimipramine Vandetanib Vardenafil Vemurafenib Venlafaxine Voriconazole Vorinostat Ziprasidone 159 medications!
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Treatment for Long QT interval
1. Reduce the medications that are causing it. 2. Change the medications that are causing it. 3. Stop the medications that are causing it!
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Wellens’ Syndrome
Dr. Hein Wellens
• Small terminal inversion of the T wave in V1, V2, V3
Wellens’ Syndrome
Dr. Hein Wellens • Recent Hx of chest pain or anginal equivalents.
• The patient may be pain-free during the exam and while the ECG is being acquired.
• Cardiac markers may be normal.
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Wellens’ Syndrome (a broader definition)
• Inverted T waves in V1, V2, V3. No loss of R waves, No Qs.
Significance of Wellens’ Syndrome
Imminent catastrophe —Yikes!
Significance of Wellens’ Syndrome
• 75% chance of massive anterior MI • Proximal LAD lesion; (50% of LV) • The patient should be referred to angiography quickly for PCI (or CABG) to prevent the MI. • Stress test is fatal!
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95% occlusion of the proximal LAD
Percutaneous Coronary Intervention
Artery before stenting After stenting (red is lumen; yellow is obstruction) Note the much larger lumen
The Spectrum of Acute Coronary Syndromes
Shock / Healthy CAD Angina Unstable Angina NSTEMI STEMI Death
Patent ~50% ~70% >70% or 100% ~90% 100% 100% artery (or vasospasm)
No symptoms Pain on Pain at rest; exertion relieved by NTG Constant pain
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Wrap it Up!
Review! WPW: • short PR • wide QRS • Delta waves • tachycardias • AF = sudden death LGL : • short PR • normal QRS • NO Delta waves • tachycardias Brugada : • elevated STs in V1, V2, V3 • RBBB pattern • at risk for VT / VF Long QT : • QTc > 450 (470 ) ms • at risk for R on T = VT / VF Wellens : • terminal T wave inversion in V1, V2, V3 • impending massive MI
Case report: 44 y.o. male comedian c/o episodes of rapid heart beat. Comes to your office for exam.
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What is the Syndrome? 12
HIPPA note: this is not Richard Pryor’s actual ECG.
But he did have WPW. 12 WPW
short PR Delta waves Wide QRS
What is the syndrome? 13 30 y.o. male with episodes of rapid heart beat
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13 LGL (short PR, normal QRS, no Delta wave)
short PR
Narrow QRSs
35 y.o. male c/o episodes of rapid heart beat. 14 Father died @ 30 y.o., sudden death.
Brugada Syndrome 14
RBBB, Elevated STs
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What is the Syndrome? 15 (extra points for the arrhythmia!)
15 Long QT interval (Wenckebach) 2nd °°° AV Block, Type I Dr. Karel Wenckebach
What is the Syndrome? 16 Chest pains on and off x 2 weeks. But no pain right now.
Quiz- Wellens’ syndrome
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Wellens’ Syndrome 16
Quiz- Wellens’ syndrome
terminal T wave inversion in V1, V2, V3
Case report: 58 y.o. male c/o chest “tightness” and shortness of breath x 20 minutes, which gradually subsided. Recurrent episodes over several months. Pt thought it was “acid reflux”, but finally goes to ED. Pt is noncompliant with statin therapy, & admits to poor diet. Family Hx cardiac disease. Hx HTN. Meds: Plavix, ACE inhibitor.
EKG follows. What treatment?
HIPPA note: this is not Bill Clinton’s actual ECG!
Angiography reveals 90% occlusion in some coronary arteries.
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But he did have CABG & became adherent to his meds…
Ischemia / Impending MI
no loss of R waves yet…
…but inverted T waves
Treatment: quadruple CABG (coronary artery bypass graft).
Excellent outcome: Pt is active, healthy, has improved diet, is compliant with meds. He inspired thousands of Americans to go to their provider for cardiac evaluations…
“The Bill Clinton Effect”
The benefits of a heart transplant
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That’s all, Folks!
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