ECG’S: A CASE-BASED APPROACH December 6, 2018 1 Faculty Disclosure Faculty: Lorne Gula MD, FRCPC Professor, Western University Cardiologist, Hearth Rhythm Specialist Director, Electrophysiology Laboratory, London, Ontario Damian Redfearn MB, ChB, MRCPI, FRCPC Heart Rhythm Service, Kingston General Hospital Relationships with commercial interests: • Not Applicable Potential for conflict(s) of interest: • Not Applicable 2 Mitigating Potential Bias •All the recommendations involving clinical medicine are based on evidence that is accepted within the profession. •Recommendations conform to the generally accepted standards. •The presentation will mitigate potential bias by ensuring that data and recommendations are presented in a fair and balanced way. 3 Learning Objectives After active participation in the workshop participants will be able to diagnose the following conditions on ECG and review principles of clinical management: •Bradycardia, conduction abnormalities, and tachycardia. •Myocardial ischemia, acute and previous myocardial infarction. •Other systemic disorders with ECG manifestations. 4 58 year old man, chest pressure, short of breath 1. Pericarditis 2. Acute inferior MI 3. Acute anterior MI 4. Ventricular tachycardia 58 year old man, chest pressure, short of breath 1. Pericarditis 2. Acute inferior MI 3. Acute anterior MI 4. Ventricular tachycardia 52 year old woman with sudden shortness of breath. Most concerning abnormality is 1. Right bundle branch block 2. AV delay 3. Anteroseptal infarction 4. Brugada sign 52 year old woman with sudden shortness of breath. Most concerning abnormality is 1. Right bundle branch block 2. AV delay 3. Anteroseptal infarction 4. Brugada sign 64 year old man, hypertension, diabetes, short of breath 1. Inferior MI 2. Left bundle branch block 3. Diffuse ischemia 4. Complete AV block 5. None of above 64 year old man, hypertension, diabetes, short of breath 1. Inferior MI 2. Left bundle branch block 3. Diffuse ischemia 4. Complete AV block 5. None of above 48 year old man, prior MI and stent, sudden chest pressure 1/2 1. Acute anterior MI 2. Acute inferior MI 3. Pericarditis 4. Ventricular tachycardia 48 year old man, prior MI and stent, sudden chest pressure 1/2 1. Acute anterior MI 2. Acute inferior MI 3. Pericarditis 4. Ventricular tachycardia 2/2 22 yo healthy young man, recent URTI, now having chest pain 1. Hyperkalemia 2. Intracranial bleed 3. Pericarditis 4. Acute MI 22 yo healthy young man, recent URTI, now having chest pain 1. Hyperkalemia 2. Intracranial bleed 3. Pericarditis 4. Acute MI 67 year old man, hypertension, routine assessment 1. Left bundle branch block 2. Right bundle branch block 3. Ventricular rhythm 4. Atrial fibrillation 67 year old man, hypertension, routine assessment 1. Left bundle branch block 2. Right bundle branch block 3. Ventricular rhythm 4. Atrial fibrillation 1/2 68 year old woman, fatigue and dizziness past 2 weeks. This patient is at risk of 1.Bradycardia 2. Tachycardia 3. Both 4. Neither 1/2 68 year old woman, fatigue and dizziness past 2 weeks. This patient is at risk of 1.Bradycardia 2. Tachycardia 3. Both 4. Neither 2/2 54 yo man preop hand surgery. What is the rhythm? 1. Sinus 2. Junctional 3. AF 4. Ventricular 5. A flutter 54 yo man preop hand surgery. What is the rhythm? 1. Sinus 2. Junctional 3. AF 4. Ventricular 5. A flutter 72 yo woman, fatigue, poor energy level. What is the diagnosis? 1. Bradycardia 2. Atrial fibrillation 3. Complete AV block 4. All of the above 5. None of the above 72 yo woman, fatigue, poor energy level. What is the diagnosis? 1. Bradycardia 2. Atrial fibrillation 3. Complete AV block 4. All of the above 5. None of the above 63 year old man known to the heart rhythm service. Routine assessment. The rhythm is 1. Sinus with PVCs 2. AF with PVCs 3. AF with pacing 4. Idioventricular 63 year old man known to the heart rhythm service. Routine assessment. The rhythm is 1. Sinus with PVCs 2. AF with PVCs 3. AF with pacing 4. Idioventricular 62 year old man, referred by sleep clinic for rhythm assessment. The conduction disturbance is most likely 1. In the sinus node 2. In the AV node 3. In the distal conduction system 4. In the His Bundle 62 year old man, referred by sleep clinic for rhythm assessment. The conduction disturbance is most likely 1. In the sinus node 2. In the AV node 3. In the distal conduction system 4. In the His Bundle 71 year old woman, 2 episodes of syncope. The conduction disturbance is most likely 1.In the sinus node 2. In the AV node 3. In the distal conduction system 4. In the His Bundle 71 year old woman, 2 episodes of syncope. The conduction disturbance is most likely 1.In the sinus node 2. In the AV node 3. In the distal conduction system 4. In the His Bundle 2○ AV block “Some p waves conduct, some don’t” • Within AV node – Mobitz 1 (‘Wenckebach’) pattern: Gradually prolonging PR until dropped QRS – narrow QRS – long-ish PR even on first beat of sequence) – Low risk of worsening block/bradycardia • Distal conduction system (below AV node) – Mobitz II pattern: Constant PR with intermittently dropped QRS – normal PR when conducted – slightly wide QRS – High risk of worsening block/bradycardia 2:1 AV conduction. The conduction disturbance is most likely 1.In the sinus node 2. In the AV node 3. In the distal conduction system 4. In the His Bundle 2:1 AV conduction. The conduction disturbance is most likely 1.In the sinus node 2. In the AV node 3. In the distal conduction system 4. In the His Bundle The conduction disturbance is most likely 1.In the sinus node 2. In the AV node 3. In the distal conduction system 4. In the His Bundle The AV conduction disturbance is 1.First degree AV delay 2. Second degree AV block 3. Complete AV block 4. Need more info The AV conduction disturbance is 1.First degree AV delay 2. Second degree AV block 3. Complete AV block 4. Need more info For clearer diagnosis it would be helpful to 1.Cardiovert 2. Pace 3. Intubate 4. Give adenosine For clearer diagnosis it would be helpful to 1.Cardiovert 2. Pace 3. Intubate 4. Give adenosine 43 yo man, renal impairment, no coronary history 1. Hypokalemia 2. Left bundle branch block 3. Diffuse ischemia 4. Hyperkalemia 5. Hypocalcemia 43 yo man, renal impairment, no coronary history 1. Hypokalemia 2. Left bundle branch block 3. Diffuse ischemia 4. Hyperkalemia 5. Hypocalcemia 32 yo woman, syncope. Mild sharp pleuritic pain. 1. Hyperkalemia 2. Intracranial bleed 3. Brugada syndrome 4. Acute MI 32 yo woman, syncope. Mild sharp pleuritic pain. 1. Hyperkalemia 2. Intracranial bleed 3. Brugada syndrome 4. Acute MI Brugada Syndrome Wilde et al Circ 2002 ;106 :2514 Asymptomatic CCU patient needs immediate 1. Thrombolytic 2. Defibrillation 3. Nitro 4. Telemetry adjustment 5. Inotropes Asymptomatic CCU patient needs immediate 1. Thrombolytic 2. Defibrillation 3. Nitro 4. Telemetry adjustment 5. Inotropes Clues to artifact • Messy baseline • QRS tracks through at regular rate • Nonphysiologic intervals • No pause after resolution 1/2 35 yo woman, stable but palpitations 1. AV node reentry 2. AV reentry (WPW) 3. Preexcited AF 4. VT 5. Need more info 1/2 35 yo woman, stable but palpitations 1. AV node reentry 2. AV reentry (WPW) 3. Preexcited AF 4. VT 5. Need more info 2/2 Same patient, after adenosine. SVT was most likely 1. AV node reentry 2. AV reentry (WPW) 3. Atrial tachycardia 4. VT 5. Need more info 2/2 Same patient, after adenosine. SVT was most likely 1. AV node reentry 2. AV reentry (WPW) 3. Atrial tachycardia 4. VT 5. Need more info 1/2 30 yo woman, stable with palpitations. Initial tx: 1. Verapamil 2. Atenolol 3. Isoproterenol 4. Procainamide 5. Cardioversion 1/2 30 yo woman, stable with palpitations. Initial tx: 1. Verapamil 2. Atenolol 3. Isoproterenol 4. Procainamide 5. Cardioversion 2/2 Sinus rhythm AF 68 yo man, stable with palpitations. Most likely: 1. VT 2. SVT with BBB 3. Pre-excited tachycardia 4. Paced 5. Artifact 68 yo man, stable with palpitations. Most likely: 1. VT 2. SVT with BBB 3. Pre-excited tachycardia 4. Paced 5. Artifact 63 yo man, no cardiac history, stable with palpitations. Initial medication: 1. Verapamil 2. Amiodarone 3. Adenosine 4. Heparin 5. Procainamide 63 yo man, no cardiac history, stable with palpitations. Initial medication: 1. Verapamil 2. Amiodarone 3. Adenosine 4. Heparin 5. Procainamide 54 yo man, no cardiac history, palpitations. Cause of palpitations: 1. AV node pathology 2. PVCs 3. PACs 4. Sinus node dysfunction 54 yo man, no cardiac history, palpitations. Cause of palpitations: 1. AV node pathology 2. PVCs 3. PACs 4. Sinus node dysfunction 42 yo man, no cardiac history, recent echo normal. Stable with palpitations. 1. SVT with RBBB 2. Pre-excited tachycardia 3. VT 4. Pacing 42 yo man, no cardiac history, recent echo normal. Stable with palpitations. 1. SVT with RBBB 2. Pre-excited tachycardia 3. VT 4. Pacing This pacemaker has: 1. One lead 2. Two leads 3. Three leads 4. Can’t tell This pacemaker has: 1. One lead 2. Two leads 3. Three leads 4. Can’t tell This pacemaker has: 1. One lead 2. Two leads 3. Three leads 4. Can’t tell This pacemaker has: 1. One lead 2. Two leads 3. Three leads 4. Can’t tell Biventricular pacemaker 1. Undersensing 2. Normal 3. Oversensing 4. Failure to capture Biventricular pacemaker 1. Undersensing 2. Normal 3. Oversensing 4. Failure to capture Questions/Discussion Lorne Gula, MD Director, Heart Rhythm Ablation Lab, London, Ontario Damian Redfearn, MB, ChB, MRCPI Director, Heart Rhythm Service, Kinston, Ontario Questions? Lorne Gula, MD Director, Heart Rhythm Ablation Lab, London, Ontario Damian Redfearn, MB, ChB, MRCPI Heart Rhythm Service, Kinston, Ontario 104 .