Supraventricular

Reading Assignment

Chapter 5 (p17-30) The Supraventricular Rhythms In Our Lives

Site of Origin Single Events Slow Rates Intermediate Rates Fast Rates (>100 bpm)

Sinus Sinus Normal sinus rhythm Sinus

Atrial PAC’s Ectopic atrial rhythm Paroxysmal SVT Atrial Ectopic (4:1 block) Atrial flutter (e.g., 2:1 block) Multifocal atrial tachycardia

Junctional PJC’s J- escape rhythm Accelerated J- rhythm (AVN, His) J- escape beats (~40-50 bpm) (~55-100 bpm) Paroxysmal SVT: -AVNRT -AVRT (WPW)

Ventricular PVC’s V- escape rhythm Accelerated V- rhythm V-escape beats (~35-45 bpm) (~50-100 bpm) Torsade de points Welcome to the “5-Step Method”

ECG #: Mearurements: Rhythm (s): Conduction: Waveform: Interpretation:

A= V=

PR=

QRS=

QT=

Axis=

1. Compute the 5 basic measurements: HR, PR interval, QRS duration, QT interval, Axis 2. What’s the basic rhythm and other rhythm statements (e.g., PACs and PVC’s) 3. Any conduction abnormalities (SA blocks, AV blocks (Types I or II), and IV blocks 4. Waveform abnormalities beginning with P waves, QRS complexes, ST-T, and U waves 5. Final interpretations: Normal ECG or Borderline or Abnormal ECG (list final conclusions) 62 year old man

4-1 2:1 4:1 3:1

Mearurements: Rhythm (s): Conduction: Waveform: Interpretation:

A= 300 V=150 Atrial flutter Mostly 2:1 AV conduction Flutter waves (arrows) are Abnormal ECG: hidden in the T and after the 1. Rhythm PR= ? QRS; normal QRS, low 2. Nonspecific abnormalities amplitude T waves QRS=80 Note; in every regular SVT @ ~150 bpm, always put atrial flutter with 2:1 block QT= ? first on the list of diferential diagnoses! 4-1 Look carefully for flutter waves. They are Axis= +45 not equally well seen in every lead. 72 year old woman; hospital day 3 Why was she admitted?

4-2 Imagine II, III, aVF with the disappearance of QRS complexes: what is left is a saw-tooth pattern of atrial flutter (best seen in the inferior leads.

4:1

Mearurements: Rhythm (s): Conduction: Waveform: Interpretation:

A= 135 V= 270 Atrial flutter • Mostly 2:1 AV conduction • flutter waves (saw-tooth) Abnormal ECG: • IVCD (QRS 110 ms) • Q‘s II, III, aVF (arrows) with 1. Rhythm and rate PR= ? questionable ST elevation 2. Inferior MI (age undertermined, (distorted by the flutter possibly recent) QRS=110 waves) 3. Incomplete RBBB; note late rightward forces in I, aVL, V6 QT= ?

4-2 Axis= ~ 0 65 year old man with chest pain

4-3 Mearurements: Rhythm (s): Conduction: Waveform: Interpretation:

A=135 V=270 Atrial flutter and 3 PVCs 2:1 AV conduction • Flutter waves (best seen in Abnormal ECG: lead II, but also seen in 1. Rhythm (atrial flutter and few PVC‘s PR= ? other leads (arrows) 2. PAF and inferior Q waves: infero- • Q‘s II, III aVF posterior (or new terminology infero- QRS= 70 • Prominent anterior forces lateral MI – age undetermined) (PAF); note R>S in V1-2 QT= ~340

4-3 Axis= +40 54 year old man admitted with HFrEF (EF 24%), elevated BNP

4-4 Mearurements: Rhythm (s): Conduction: Waveform: Interpretation:

A= ? V= ~75 Atrial fibrillation • Moderate heart rate • A-fib activity Abnormal ECG: response to A-fib • Huge voltage for LVH (V1-3) 1. Rhythm (A-fib) PR= ? • normal IV • T wave inversion I, aVL, V5,6 2. LVH with strain pattern • Poor R wave progression V1-4 QRS=100

QT=360

4-4 Axis= -20 I

II

III

V1

81 year old man with hypertension; what are those two FLB’s? 4-5 I

II

III

rsR’ 4:1 2:1 Mearurements: Rhythm (s): Conduction: Waveform: Interpretation: A=300 V=75 Atrial flutter Mostly 4:1 and occasional • Flutter waves Abnormal ECG:

2:1 AV conduction with • rS II, III, aVF with SIII>SII 1. Rhythm (atrial flutter) V1 PR= ? RBBB aberrant conduction • Small q in aVL 2. Left anterior fascicular block (arrow) • LVH voltage (V2) with (LAFB) QRS=110 ST-T strain pattern 3. LVH with strain

QT=340 4-5 Axis= -60 SG: 62 year old man Official Interpretation:

4-6a Mearurements: Rhythm (s): Conduction: Waveform: Interpretation:

A= 280 V=140 Atrial flutter Mostly 2:1 AV conduction • Flutter waves (blue arrows) Abnormal ECG (note: mostly fixed • T wave inversion V1-4 1. Rhythm (atrial flutter) PR= ? (constant) RR intervals – • Small Q‘s II, III, aVF rules out A-fib) • Note presence of artifact in 2. Nonspecific T abnormality QRS=70 some of the leads (red 3. Possible old inferior MI arrows) QT= ~320 4-6a Axis= +10 JS: 82 year old woman Official Interpretation:

4-6b Mearurements: Rhythm (s): Conduction: Waveform: Interpretation:

A= ? V= 110 Atrial fibrillation Rapid ventricular • A-fib activity (best seen in Abnormal ECG: response (>100 bpm) V1 lead, not classic flutter 1. Rhythm (A-fib) and rate PR= ? waves) 2. Nonspecific T wave abnormalities • Low amplitude T waves (minor) QRS=70 Note: The coarse a-fib activity in V1 somewhat resembles atrial flutter, but QT=320 they are not equally spaced and have slightly varying morphology; this and the 4-6b Axis= -10 irregular RR intervals means A-fib) 58 year old man with palpitations

4-7 6:5 group 5:4 group 5:4 group

Mearurements: Rhythm (s): Conduction: Waveform: Interpretation:

A= 150 V=120 Two choices: 2nd degree AV block Normal P, QRS, ST-T Abnormal ECG: • vs. (type I, Wenckebach) 1. Rhythm and rate PR= variable • Ectopic atrial tachycardia 2. 2nd degree AVB (type 1) (more likely) Note: repetitive group 3. Borderline (LAD) QRS=80 (P wave morphology and axis beating suggests sinus, but heart rate QT=320 is a little too fast for a resting ECG in sinus rhythm) 4-7 Axis=-30 32 year old man with idiopathic pulmonary hypertension

4-8 These are not sinus P waves

Mearurements: Rhythm (s): Conduction: Waveform: Interpretation:

A= 110 V= 110 Ectopic atrial tachycardia Normal AV, IV • Ectopic P wave morphology Abnormal ECG: conduction (can‘t be sinus, see arrows) 1. Rhythm PR=140 • Prominent anterior forces 2. (RAD) • ST depression, T wave 3. RAE (based on tall P in V1-2 even QRS=90 inversion in II, III, aVF, V1-6 though not sinus rhythm) 4. RVH with strain pattern QT=360 4-8 Axis= +150 55 year old man with palpitations

4-9 Mearurements: Rhythm (s): Conduction: Waveform: Interpretation: A= 160 V= 160 Supraventricular Normal IV • ST depression I, II, aVL, V3-6 Abnormal ECG: tachycardia (most likely 1. Rhythm and rate; AVNRT is most PR= none AVNRT) likely diagnosis because there is a hint of retrograde P waves just after QRS= 80 QRS in V1 (arrows) 2. ST depression suggestive of QT= 300 (kind of like a + ECG stress test)

4-9 Axis= +10 F, Age 89

I

II

III

V1

89 year old woman with intermittent palpitations; history of chronic HFrEF 4-10 F, Age 89

I

II Mearurements: Rhythm (s): Conduction: Waveform: Interpretation:

A= ~65 V=165 (SVT) 1. Three Sinus (*) with 2 Normal SA, AV, slightly • Monophasic R in I and aVL Abnormal ECG: PACs (blue arrows) wide QRS (IVCD) • Poor R progression (V1-5) 1. Rhythm (PAC‘s and AVNRT) PR=200 2. Early PAC (green arrow) • LV voltage cruteria + 2. LVH with ST-T abnormalities initiates AVNRT (AV nodal • ST-T changes of LV strain 3. Incomplete LBBB (often seen with QRS=110 reentrant tachycardia) • Retrograde P waves during severe LVH) the SVT (red arrows) QT=360

III Axis= -15

* * * V1

4-10 77 y.o. woman in E.R. with dyspnea and ↑ BNP

4-11 * *

Mearurements: Rhythm (s): Conduction: Waveform: Interpretation:

A= varies V= ~150 Multifocal atrial Normal AV, IV • Multifocal atrial activity Abnormal ECG: tachycardia (MAT) (note varying P wave 1. Rhythm (MAT) and rate PR= varies morphology in V1, II, III) • 2 incomplete RBBB QRS=70 aberrancies (*), classic rsR‘ - not to be confused with QT= ~320 PVC‘s.

4-11 Axis= +70 I

II

III

V1

4-12 I

II

Mearurements: Rhythm (s): Conduction: Waveform: Interpretation:

A= varies V= ~110 Multifocal atrial Normal AV, IV • Multifocal atrial activity Abnormal ECG: tachycardia (MAT) conducted and 1. Rhythm (MAT) and rate PR= varies nonconducted (*) 2. Nonspecific ST-T changes • Minor ST-T abnormalities QRS=70

QT= ~320

III Axis= +30

* * * * * V1

4-12 November, 2002: 49 year old woman with altered mental status (found in Pioneer Park)

4-13 ‘J’

Mearurements: Rhythm (s): Conduction: Waveform: Interpretation:

A= ? V= ~110 Atrial fibrillation with Normal AV and IV • ‘J‘ waves or Osborn waves Abnormal ECG: rapid HR response (J waves are created when 1. Rhythm and rate PR= the epicardial cells are 2. Hypothermia cooler than the 3. Nonspecific T abnormalities QRS=80 endocardial cells; they are 4. Prolonged QT (seen in hypothermia) also seen in other electrical QT=~440 heart diseases, and in hypercalcemia) 4-13 Axis= +60 • Low amplitude T waves JM: 56 y.o. man with palpitations; looks complicated, doesn’t it?

4-14 4 beat VT 1 PVC

3:2 conduction 2:1 conduction

Mearurements: Rhythm (s): Conduction: Waveform: Interpretation:

A=250 V= ~200 • Atrial flutter (arrows) Both 2:1 and 3:2 AV • rsR‘ alternating with qR in Abnormal ECG: • 4-beat V-tachycardia conduction are seen with lead V1 1. Rhythms and rate PR= varies • 1 PVC the atrial flutter 2. Incomplete RBBB

QRS=80, and 100 What initially looks complicated can be resolved by breaking up the rhythm into QT=~240 segments, looking carefully for atrial activity, atrial rate, and how each atrial 4-14 Axis= -75 event relates to the QRS‘s (arriws) I

II

III

V1

4-15 I

II

III

Mearurements: Rhythm (s): Conduction: Waveform: Interpretation: V1 A=250 V=125 Atrial flutter (arrows) • 2:1 AV conduction • rsR‘ in V1 Abormal ECG: • IVCD (RBBB) • Late S (rightward 1. Rhythm and rate PR= ? Note: every other flutter force) in I, aVL, V5-6 2. RBBB wave is hidden at end of the QRS=150 R‘ of RBBB. Lead V1 is the only good lead in this ECG for QT=360 identifying the rhythm. 4-15 Axis= 0