Accelerated Junctional Rhythm in Athlete's Heart: an Un-Usual
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Clinical Significance of Exit Block*
Clinical Significance of Exit Block* IRANY M. DE AZEVEDO, M.D. YOSHIO WATANABE, M.D. LEONARD S. DREIFUS, M.D. From the Departments of Medicine, Physiology, and Biophysics, Hahnemann Medical College, Philadelphia, Pennsylvania The confinement of an ectopic discharge to its ily reserved for ectopic pacemakers, rather than the focus, and its consequent inability to invade the ad sinus node. jacent myocardium when falling outside of the re High Grade Atrioventricular Block. In vi rtu fractory period of the heart, is a well established ally all instances, exit block occurs in the presence phenomenon called "exit block." This cardiac ar of higher degrees of A-V block. Failure of the rhythmia was originally described by Kaufmann impulse to propagate from the subsidiary ectopic and Rothberger ( 8) to explain the failure of a para focus to either the ventricles, atria, or both is char systolic focus to activate the heart. All pacemakers acteristic of this form of exit block. Several exam are subject to exit block (9, 13, 15, 14, 11 , 16, 12, ples are illustrated. In figure 2, there is high grade 3, 10, 7, 1), however, by convention, conduction A-V block causing A-V dissociation. The atria are disturbances involving the sinus node (S-A block) under the control of the sinus node at a rate of 71 are usually excluded from this concept, and the term per minute, and the ventricles are controlled by a is reserved for ectopic pacemakers. Recent electro subsidiary ectopic pacemaker, probably originating physiological and clinical studies have shown that in the right bundle branch at a rate of approximately exit block may complicate reentrant arrhythmias and 40 per minute. -
Cardiology-EKG Michael Bradley
Cardiology/EKG Board Review Michael J. Bradley D.O. DME/Program Director Family Medicine Residency Objectives • Review general method for EKG interpretation • Review specific points of “data gathering” and “diagnoses” on EKG • Review treatment considerations • Review clinical cases/EKG’s • Board exam considerations EKG EKG – 12 Leads • Anterior Leads - V1, V2, V3, V4 • Inferior Leads – II, III, aVF • Left Lateral Leads – I, aVL, V5, V6 • Right Leads – aVR, V1 11 Step Method for Reading EKG’s • “Data Gathering” – steps 1-4 – 1. Standardization – make sure paper and paper speed is standardized – 2. Heart Rate – 3. Intervals – PR, QT, QRS width – 4. Axis – normal vs. deviation 11 Step Method for Reading EKG’s • “Diagnoses” – 5. Rhythm – 6. Atrioventricular (AV) Block Disturbances – 7. Bundle Branch Block or Hemiblock of – 8. Preexcitation Conduction – 9. Enlargement and Hypertrophy – 10. Coronary Artery Disease – 11. Utter Confusion • The Only EKG Book You’ll Ever Need Malcolm S. Thaler, MD Heart Rate • Regular Rhythms Heart Rate • Irregular Rhythms Intervals • Measure length of PR interval, QT interval, width of P wave, QRS complex QTc • QTc = QT interval corrected for heart rate – Uses Bazett’s Formula or Fridericia’s Formula • Long QT syndrome – inherited or acquired (>75 meds); torsades de ponites/VF; syncope, seizures, sudden death Axis Rhythm • 4 Questions – 1. Are normal P waves present? – 2. Are QRS complexes narrow or wide (≤ or ≥ 0.12)? – 3. What is relationship between P waves and QRS complexes? – 4. Is rhythm regular or irregular? -
Wide Flbs & QRS Tachycardias
Wide FLB’s and QRS Tachycardias Reading Assignment (p30-41 and 42-44) 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) 44 Year old man in the ER with palpitations and lightheadedness 7-1 rsR’ Mearurements: Rhythm (s): Conduction: Waveform: Interpretation: A= V=210 Wide QRS tachycardia • IVCD • rsR‘ in V1 Abnormal ECG: • Late S (rightward forces) in 1. High probability SVT with RBBB PR= I, aVL, V6 Clues: classic triphasic (rsR‘) RBBB QRS=1120 morphology in V1 is very unlikely to be VT. The most likely SVT mechanism in this QT=240 ECG is AVNRT with RBBB. 7-1 Axis= indeterminate 65 Year old man in the ICU with hypotension 7-2 qR in V1 rS in V6 Mearurements: Rhythm (s): Conduction: Waveform: Interpretation: A= V=140 Wide QRS tachycardia • IVCD • Northwest quadrant axis Abnormal ECG: (lead I and II both negative) • Left ventricular tachycardia PR= • qR pattern in V1 • rS pattern in V6 ECG Clues for VT in this case: 1) NW QRS=150 quadrant axis; 2) qR in V1; rS in V6. QT=340 Clinical clues: hypotension 7-2 Axis= -120 (NW Quadrant) I II III 7-3 75 Year old man in the ICU with recent acute coronary syndrome Mearurements: Rhythm (s): Conduction: Waveform: Interpretation: A= V= 135 Wide QRS tachycardia • IVCD • fat R in V1 (red arrows) Abnormal ECG: • Notch on downstroke of S 1. -
Evidence of Atrial Functional Mitral Regurgitation Due to Atrial Fibrillation Reversal with Arrhythmia Control
Journal of the American College of Cardiology Vol. 58, No. 14, 2011 © 2011 by the American College of Cardiology Foundation ISSN 0735-1097/$36.00 Published by Elsevier Inc. doi:10.1016/j.jacc.2011.06.032 Heart Rhythm Disorders Evidence of Atrial Functional Mitral Regurgitation Due to Atrial Fibrillation Reversal With Arrhythmia Control Zachary M. Gertz, MD,* Amresh Raina, MD,* Laszlo Saghy, MD,† Erica S. Zado, PA-C,* David J. Callans, MD,* Francis E. Marchlinski, MD,* Martin G. Keane, MD,* Frank E. Silvestry, MD* Philadelphia, Pennsylvania; and Szeged, Hungary Objectives The purpose of this study was to determine whether atrial fibrillation (AF) might cause significant mitral regurgi- tation (MR), and to see whether this MR improves with restoration of sinus rhythm. Background MR can be classified by leaflet pathology (organic/primary and functional/secondary) and by leaflet motion (nor- mal, excessive, restrictive). The existence of secondary, normal leaflet motion MR remains controversial. Methods We performed a retrospective cohort study. Patients undergoing first AF ablation at our institution (n ϭ 828) were screened. Included patients had echocardiograms at the time of ablation and at 1-year clinical follow-up. The MR cohort (n ϭ 53) had at least moderate MR. A reference cohort (n ϭ 53) was randomly selected from those patients (n ϭ 660) with mild or less MR. Baseline echocardiographic and clinical characteristics were compared, and the effect of restoration of sinus rhythm was assessed by follow-up echocardiograms. Results MR patients were older than controls and more often had persistent AF (62% vs. 23%, p Ͻ 0.0001). -
Parasystole in a Mahaim Accessory Pathway
223 Case Report Parasystole in a Mahaim Accessory Pathway Chandramohan Ramasamy MD, Senthil Kumar MD, Raja J Selvaraj MD, DNB Department of Cardiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India Address for Correspondence: Dr. Raja J Selvaraj, Assistant Professor of Cardiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry - 605006, India. E-Mail: [email protected] Abstract Automaticity has been described in Mahaim pathways, both spontaneously and during radiofrequency ablation. We describe an unusual case of automatic rhythm from a Mahaim pathway presenting as parasystole. The parasystolic beats were also found to initiate tachycardia, resulting in initial presentation with incessant tachycardia and tachycardia induced cardiomyopathy. Key words: Mahaim tachycardia, Parasystole, Automaticity Introduction Mahaim pathways are atriofascicular accessory pathways with decremental, anterograde only conduction. The most common clinical manifestation related to these pathways is antidromic reentrant tachycardia. Less commonly, the pathway may be a bystander with atrioventricular nodal reentrant tachycardia or atrial tachycardia. Rarely, automaticity has been reported from the pathway, manifesting as ectopic beats during sinus rhythm or as an automatic tachycardia [1,2]. Parasystole is a condition where an ectopic focus is unaffected by the underlying rhythm due to entrance block. Parasystole has been reported from atrial musculature, ventricular musculature -
Clinical Manifestation and Survival of Patients with I Diopathic Bilateral
ORIGINAL ARTICLE Clinical Manifestation and Survival of Patients with Mizuhiro Arima, TatsujiI diopathicKanoh, Shinya BilateralOkazaki, YoshitakaAtrialIwama,DilatationAkira Yamasaki and Sigeru Matsuda Westudied the histories of eight patients who lacked clear evidence of cardiac abnormalities other than marked bilateral atrial dilatation and atrial fibrillation, which have rarely been dis- cussed in the literature. From the time of their first visit to our hospital, the patients' chest radio- graphs and electrocardiograms showed markedly enlarged cardiac silhouettes and atrial fibrilla- tion, respectively. Each patient's echocardiogram showed a marked bilateral atrial dilatation with almost normal wall motion of both ventricles. In one patient, inflammatory change was demonstrated by cardiac catheterization and endomyocardial biopsy from the right ventricle. Seven of our eight cases were elderly women.Over a long period after the diagnosis of cardiome- galy or arrhythmia, diuretics or digitalis offered good results in the treatment of edema and congestion in these patients. In view of the clinical courses included in the present study, we conclude that this disorder has a good prognosis. (Internal Medicine 38: 112-118, 1999) Key words: cardiomegaly, atrial fibrillation, elder women,good prognosis Introduction echocardiography. The severity of mitral and tricuspid regur- gitation was globally assessed by dividing into three equal parts Idiopathic enlargement of the right atrium was discussed by the distance from the valve orifice. The regurgitant jet was de- Bailey in 1955(1). This disorder may be an unusual congenital tected on color Doppler recording in the four-chamber view malformation. A review of the international literature disclosed and classified into one of the three regions (-: none, +: mild, that although several cases have been discussed since Bailey's ++:moderate, +++: severe). -
Brugada Syndrome Associated to Myocardial Ischemia Sindrome De Brugada Associado a Isquemia Miocárdica
Brugada syndrome associated to Myocardial ischemia Sindrome de Brugada associado a isquemia miocárdica Case of Dr Raimundo Barbosa Barros From Fortaleza - Ceará - Brazil Caro amigo Dr. Andrés Gostaria de ouvir a opinião dos colegas do foro sobre este paciente masculino 56anos internado na emergência do nosso hospital dia 03 de Novembro de 2010. Relata que em abril deste ano foi internado por quadro clínico compatível com angina instável (ECG1). Na ocasião foi submetido à coronariografia que revelou lesão crítica proximal da arteria descendente anterior e lesão de 90% na porção distal da artéria coronária direita. Nesta ocasião realizou angioplastia com colocação de stent apenas na artéria descendente anterior ( ECG2 pós ATC) A artéria coronaria direita não foi abordada. O paciente evoluiu assintomático(ECG3). Em 20/09/2010 realizou cintilografia miocárdica de rotina que resultou normal. No dia 03 de novembro de 2010 procura emergência refirindo ter sofrido episódio de sincope precedido de palpitações rápidas e desconforto torácico atípico.(ECGs 4 e 5). Adicionalmente, informa que 4 horas antes da sua admissão havia apresentado febre (não documentada). Não há relato de episódio prévio semelhante ou história familiar positiva para Morte súbita em familiar jovem de primeiro grau. Dosagem seriada de CK-MB e troponina normais. Qual os diagnósticos ECGs e qual a conduta? Um abraço para todos Raimundo Barbosa Barros Fortaleza Ceará Brasil Dear friend, Dr. Andrés, I would like to know the opinion from the colleagues of the forum about this patient (male, 56 years old), admitted in the ER of our hospital, on November 3rd, 2010. He claims that in April of this year he was admitted with symptoms of unstable angina (ECG1). -
Accelerated Junctional Rhythm on a Routine Electrocardiogram: an Unusual Presentation of Cardiac Sarcoidosis
10 The Open Cardiovascular Imaging Journal, 2011, 3, 10-12 Open Access Accelerated Junctional Rhythm on a Routine Electrocardiogram: An Unusual Presentation of Cardiac Sarcoidosis Srikanth Seethalaa, Kara Albrightb, Srinivasa V. Jampanab and Jan Nmec*,c aDepartment of Internal Medicine, Texas Tech University Health Sciences Center-El Paso; bUniversity of Pittsburgh- MedicalCenters-MercyHospital; cCardiovascular Institute, University of Pittsburgh, 200 Lothrop St, Pittsburgh, PA 15213, USA Abstract: Cardiac sarcoidosis is an uncommon cause of cardiac arrhythmias and cardiomyopathy. We describe a case of cardiac sarcoidosis presenting as an accelerated junctional rhythm and complete atrioventricular (AV) block, without se- vere left ventricular (LV) dysfunction or pulmonary symptoms. Computer tomography (CT) of the chest and mediastinal lymph node biopsy confirmed the diagnosis. Dual-chamber implantable cardioverter-defibrillator was implanted due to reported risk of sudden cardiac death due to ventricular tachyarrhythmia despite negative programmed ventricular stimula- tion. Keywords: Cardiac sarcoidosis, Accelerated junctional rhythm, AV block. CASE REPORT: Placement of dual-chamber pacemaker was considered because of probably symptomatic complete heart block. An A 66-year old male was noted to have an abnormal elec- echocardiogram repeated prior to pacemaker implantation trocardiogram (ECG) during a routine insurance exam. again showed low-normal left ventricular ejection fraction Subsequent ECG obtained in his primary care physician’s (LVEF) with regional wall motion abnormalities and mild office revealed junctional rhythm at 56 beats/minute (bpm) LV enlargement (LV diastolic diameter of 60 mm). and a slightly faster sinus rhythm with atrioventricular (AV) dissociation, suggestive of possible heart block (Fig. 1a). An A baseline chest roentgenogram (CXR) performed on the ECG obtained during another office visit again showed AV day of the device placement (Fig. -
Young Adults. Look for ST Elevation, Tall QRS Voltage, "Fishhook" Deformity at the J Point, and Prominent T Waves
EKG Abnormalities I. Early repolarization abnormality: A. A normal variant. Early repolarization is most often seen in healthy young adults. Look for ST elevation, tall QRS voltage, "fishhook" deformity at the J point, and prominent T waves. ST segment elevation is maximal in leads with tallest R waves. Note high take off of the ST segment in leads V4-6; the ST elevation in V2-3 is generally seen in most normal ECG's; the ST elevation in V2- 6 is concave upwards, another characteristic of this normal variant. Characteristics’ of early repolarization • notching or slurring of the terminal portion of the QRS wave • symmetric concordant T waves of large amplitude • relative temporal stability • most commonly presents in the precordial leads but often associated with it is less pronounced ST segment elevation in the limb leads To differentiate from anterior MI • the initial part of the ST segment is usually flat or convex upward in AMI • reciprocal ST depression may be present in AMI but not in early repolarization • ST segments in early repolarization are usually <2 mm (but have been reported up to 4 mm) To differentiate from pericarditis • the ST changes are more widespread in pericarditis • the T wave is normal in pericarditis • the ratio of the degree of ST elevation (measured using the PR segment as the baseline) to the height of the T wave is greater than 0.25 in V6 in pericarditis. 1 II. Acute Pericarditis: Stage 1 Pericarditis Changes A. Timing 1. Onset: Day 2-3 2. Duration: Up to 2 weeks B. Findings 1. -
'Pseudo'- Syndromes in Cardiology
Blood, Heart and Circulation Review Article ISSN: 2515-091X Review: ‘Pseudo’- syndromes in cardiology Mishra A1, Mishra S2 and Mishra JP2* 1Georgetown University, Washington, DC, USA 2Upstate Cardiology, Summit St, Batavia, New York, USA Abstract The term ‘pseudo’ means ‘false’, ‘pretended’, ‘unreal’, or ‘sham’ and it is likely to be of Greek origin, pseudes means false. There are a number of ‘pseudo’ terms and syndromes that we see in the practice of cardiology. Even though the meaning of pseudo is unreal or sham, however these syndromes are true entities as described below. These terms appear more ‘mimicking’ a diagnosis than being truly ‘sham’! We attempted to put together most of the ‘pseudo’-diagnoses under one heading for reference and convenience. However, every condition cannot be described here in full details and the references are available for further studies. Takotsubo cardiomyopathy (Pseudo acute myocardial • Minimal or no cardiac enzyme elevation. infarction) • No significant ST-elevation (<1 mm). This condition was first described in patients in Japan in 1990 • No pathological Q waves in precordial leads. presenting and mimicking as acute coronary syndrome (ACS) with chest pains, ST changes on ECG and mild cardiac enzyme elevation • Deeply inverted or biphasic T waves in V2-3 or sometimes V4-6. consistent otherwise with acute myocardial infarction (AMI). Imaging These changes seen during pain-free period. studies show LV apical ballooning and therefore being called Takotsubo Similar changes can be seen in the setting of chest pains along cardiomyopathy (meaning “Octopus pot”) However, coronary with above noted criteria, however without having any critical LAD angiography in these patients will at best reveal mild atherosclerosis [1]. -
Basic Rhythm Recognition
Electrocardiographic Interpretation Basic Rhythm Recognition William Brady, MD Department of Emergency Medicine Cardiac Rhythms Anatomy of a Rhythm Strip A Review of the Electrical System Intrinsic Pacemakers Cells These cells have property known as “Automaticity”— means they can spontaneously depolarize. Sinus Node Primary pacemaker Fires at a rate of 60-100 bpm AV Junction Fires at a rate of 40-60 bpm Ventricular (Purkinje Fibers) Less than 40 bpm What’s Normal P Wave Atrial Depolarization PR Interval (Normal 0.12-0.20) Beginning of the P to onset of QRS QRS Ventricular Depolarization QRS Interval (Normal <0.10) Period (or length of time) it takes for the ventricles to depolarize The Key to Success… …A systematic approach! Rate Rhythm P Waves PR Interval P and QRS Correlation QRS Rate Pacemaker A rather ill patient……… Very apparent inferolateral STEMI……with less apparent complete heart block RATE . Fast vs Slow . QRS Width Narrow QRS Wide QRS Narrow QRS Wide QRS Tachycardia Tachycardia Bradycardia Bradycardia Regular Irregular Regular Irregular Sinus Brady Idioventricular A-Fib / Flutter Bradycardia w/ BBB Sinus Tach A-Fib VT PVT Junctional 2 AVB / II PSVT A-Flutter SVT aberrant A-Fib 1 AVB 3 AVB A-Flutter MAT 2 AVB / I or II PAT PAT 3 AVB ST PAC / PVC Stability Hypotension / hypoperfusion Altered mental status Chest pain – Coronary ischemic Dyspnea – Pulmonary edema Sinus Rhythm Sinus Rhythm P Wave PR Interval QRS Rate Rhythm Pacemaker Comment . Before . Constant, . Rate 60-100 . Regular . SA Node Upright in each QRS regular . Interval =/< leads I, II, . Look . Interval .12- .10 & III alike .20 Conduction Image reference: Cardionetics/ http://www.cardionetics.com/docs/healthcr/ecg/arrhy/0100_bd.htm Sinus Pause A delay of activation within the atria for a period between 1.7 and 3 seconds A palpitation is likely to be felt by the patient as the sinus beat following the pause may be a heavy beat. -
Rhythms & Cardiac Emergencies
Rhythm & 12 Lead EKG Review March 2011 CE Condell Medical Center EMS System Site code # 107200E-1211 Prepared by: FF/PMD Michael Mounts – Lake Forest Fire Revised By: Sharon Hopkins, RN, BSN, EMT-P Objectives Upon successful completion of this module, the EMS provider will be able to: • Identify the components of a rhythm strip • Identify what the components represent on the rhythm strip • Identify criteria for sinus rhythms • Identify criteria for atrial rhythms • Identify AV/junctional rhythms Objectives cont. • Identify ventricular rhythms • Identify rhythms with AV blocks • Identify treatments for different rhythms • Identify criteria for identification of ST elevation on 12 lead EKG’s • Identify EMS treatment for patients with acute coronary syndrome (ST elevation) • Demonstrate standard & alternate placement of ECG electrodes for monitoring Objectives cont. • Demonstrate placement of electrodes for obtaining a 12 lead EKG • Demonstrate the ability to identify a variety of static or dynamic EKG rhythm strips • Demonstrate the ability to identify the presence or absence of ST elevation when presented with a 12 lead EKG • Review department’s process to transmit 12 lead EKG to hospital, if capable • Successfully complete the post quiz with a score of 80% or better. ECG Paper • What do the boxes represent? • How do you measure time & amplitude? Components of the Rhythm Strip • ECG Paper • Wave forms • Wave complexes • Wave segments • Wave intervals Wave Forms, Complexes, Segments & Intervals • P wave – atrial depolarization • QRS – Ventricular