1

Jon

Tard

iff,

BS,

PA

-C

EK

G:

Lif

e-T

hrea

teni

ng S

yndr

omes

Cli

nica

l Ass

ista

nt P

rofe

ssor

jont

ardi

ff@

aol.c

omD

iscl

osur

es

• I

wor

k fo

r V

irgi

nia

Gar

cia

M

emor

ial H

ealth

Cen

ter,

B

eave

rton

, OR

.

• And

I a

m a

med

ical

edi

tor

for

Jone

s &

Bar

tlett

Publ

ishi

ng.

3

Goa

ls o

f thi

s se

ssio

n:

Iden

tify:

• W

PW (

Wol

ff-P

arki

nson

-Whi

te)

synd

rom

e

• L

GL

(L

own-

Gan

ong-

Lev

ine)

syn

drom

e

• B

ruga

da s

yndr

ome

• L

ong

QT

syn

drom

e

• W

elle

ns s

yndr

ome

• &

mor

e!

Wha

t a 1

2-L

ead

EK

G c

an h

elp

you

do

• D

iagn

ose

AC

S / A

MI

• In

terp

ret a

rrhy

thm

ias

• Id

enti

fy li

fe-t

hrea

teni

ng s

yndr

omes

(W

PW

, L

GL

, Lon

g Q

T s

ynd.

, Wel

lens

’ sy

nd.,

etc)

• In

fer

elec

trol

yte

imba

lanc

es• 

Infe

r hy

pert

roph

y of

any

cha

mbe

r• 

Infe

r C

OPD

, per

icar

ditis

, dru

g ef

fect

s, a

nd

mor

e!

Top

10 C

ause

s of

Dea

th I

n U

SA~

2,00

0,00

0 de

aths

/ ye

ar

*

* if

you

are

< 5

5 y.

o., t

raum

a is

you

r m

ost l

ikel

y ri

sk!

Not

sho

wn

are

deat

hs d

ue t

o m

edic

al e

rror

s :

~50,

000

– 10

0,00

0 /

year

!

Pace

mak

er L

ead

Rev

ersa

l in

a D

ual-

Cha

mbe

r Pa

cem

aker

yike

s!

WPW

Gra

phic

Wol

ff-P

arki

nson

-Whi

te s

yndr

ome

(Bun

dle

of K

ent)

Wol

ff-P

arki

nson

-Whi

te S

yndr

ome

• Sh

ort P

R I

nter

val

• W

ide

QR

S •

“Del

ta”

wav

e in

som

e le

ads

• C

ause

s ta

chyc

ardi

as •

Mim

icks

MI,

BB

B

• Pt

is a

t-ri

sk f

or s

udde

n de

ath

(“R

on

T”;

atr

ial fi

brill

atio

n)•

Inci

denc

e m

ay b

e 1/

1000

Drs

. Wol

ff,

Park

inso

n,an

d W

hite

WPW

-Ade

nsoi

ne C

onve

rsio

n

WPW

pat

tern

Ort

hodr

omic

(nor

mal

) c

ondu

ctio

n

Ant

idro

mic

(ret

rogr

ade)

co

nduc

tion

PSV

T

Val

salv

a

Ade

nosi

ne

NSR

WPW

mim

icki

ng V

TA

F w

ith

WP

W—

rapi

d ve

ntri

cula

r ra

te!

• C

ardi

over

t, o

r A

mio

daro

ne

Defi

brill

ate!

A-F

ib w

ith

WP

W d

egen

erat

ing

to V

-Fib

Low

n-G

anon

g-L

evin

e sy

ndro

me

• A “

Shor

t P

R S

yndr

ome”

• N

orm

al Q

RS

(NO

T w

ide)

• N

o “D

elta

” w

ave

• M

ust

also

hav

e ep

isod

es o

f ta

chyc

ardi

a in

ord

er t

o be

cal

led

LG

L s

yndr

ome.

(O

ther

wis

e it

’s j

ust

a sh

ort

PR

inte

rval

.)

Dr.

Low

nD

r. G

anon

gD

r. L

evin

e

Low

n G

anon

g L

evin

e

• Acc

esso

ry p

athw

ay b

ypas

ses

A

V n

ode—

inse

rts

into

His

bun

dle

• T

his

shor

tens

the

PR

inte

rval

• B

ut t

he Q

RS

is n

orm

al (

NO

T w

ide)

•

and

ther

e is

No

“Del

ta”

wav

e•

May

hav

e re

cipr

ocat

ing

tach

ycar

dias

Shor

t P

R

Jam

es fi

bers

LG

L (

48 y

.o. F

)L

GL

?

Shor

t P

R

But

QR

S is

nar

row

,an

d N

O d

elta

wav

e

Bru

gada

Syn

drom

e(a

“ch

anne

lopa

thy”

)

• So

dium

cha

nnel

def

ect

(

the

QR

S is

a s

odiu

m e

vent

)•

RB

BB

on

EK

G, w

ith S

T

el

evat

ion

in V

1 -

V3

• SU

DS

(Sud

den

Une

xpla

ined

D

eath

Syn

drom

e)•

10%

of

thes

e pa

tient

s di

e / y

ear

• IC

D is

life

-sav

ing

Dr.

Ped

ro B

ruga

da

Poly

mor

phic

VT

in p

atie

nts

with

Bru

gada

Syn

drom

e

“R o

n T

” (a

PV

C o

n th

e T

wav

e) c

ause

s V

T &

sud

den

deat

h

R o

n T

Abs

olut

eR

efra

ctor

yP

erio

d

Rel

ativ

e R

efra

ctor

yP

erio

d(v

ulne

rabl

e pe

riod

)“R

on

T”

phen

omen

on(P

VC

on

T w

ave

prec

ipit

atin

g V

-Tac

h)

“R o

n T

”To

rsad

es d

e P

oint

es

Ven

tric

ular

Fib

rilla

tion

Lon

g Q

T S

yndr

ome

• Se

vera

l inh

erite

d fo

rms,

plu

s te

mpo

rary

, & ia

trog

enic

cau

ses

• Q

Tc I

nter

val >

450

mS

(>

470

mS

)

(no

rmal

QTc

is 4

00 m

S)•

Inci

denc

e m

ay b

e 1/

5000

•

A p

ossi

ble

caus

e fo

r SI

DS

• P

atie

nt is

at

risk

for

sud

den

deat

h fr

om R

on

T, T

orsa

des

de P

oint

es•

Bet

a bl

ocke

rs a

re th

erap

eutic

, alo

ng w

ith li

miti

ng p

hysi

cal a

ctiv

ity•

Impl

ante

d ca

rdio

vert

er /

defib

rilla

tor

(IC

D)

is li

fe-s

avin

g

Tors

ades

de

poin

tes

(pol

ymor

phic

V-T

ach)

Lon

g Q

T S

yndr

ome

(use

V3,

or

V4,

or

long

est Q

T in

terv

al o

n 12

-Lea

d)

Pad

/ P

addl

e P

lace

men

t

For:

• p

acin

g • d

efib

rilla

tion

• syn

chro

nize

d ca

rdio

vers

ion

For c

onsc

ious

V-T

ach,

and

SVT

. Sy

nchr

oniz

ed s

hock

del

iver

s en

ergy

syn

chro

nize

d to

the

R

wav

e.

How

ever

, for

V-F

ib a

nd

unco

nsci

ous

V-Ta

ch, d

efib

rilla

te

inst

ead

with

uns

ynch

roni

zed

shoc

k.

Sync

hron

ized

Car

diov

ersi

on

ICD

Sho

ckin

g V

-Tac

h

ICD

is li

fe-

savi

ng fo

r pa

tient

s w

ith

Long

QT

synd

rom

e

24

The

“Top

3”

Cau

ses

of A

rrhy

thm

ias

1. 

Med

icat

ions

2. 

Med

icat

ions

3. 

Med

icat

ions

25

Trea

tmen

t for

Lon

g Q

T in

terv

al

1. 

Stop

the

med

icat

ions

that

are

cau

sing

it!

2. 

Stop

the

med

icat

ions

that

are

cau

sing

it!

3. 

Stop

the

med

icat

ions

that

are

cau

sing

it!

26

Med

s th

at p

rolo

ng th

e Q

T in

terv

al

Her

e th

ey a

re!

Alb

uter

ol (

salb

utam

ol)

Alfu

zosi

n

Am

anta

dine

Am

ioda

rone

Am

itript

ylin

e

Am

phet

amin

e

Ana

grel

ide

Apo

mor

phin

e

Arf

orm

oter

ol

Aripi

praz

ole

Ars

enic

triox

ide

Art

enim

ol+

pipe

raqu

ine

Ata

zana

vir

Ato

mox

etin

e

Azi

thro

myc

in

Bed

aqui

line

Bor

tezo

mib

Bos

utin

ib

27

Med

s th

at p

rolo

ng th

e Q

T in

terv

al

Cer

itin

ib

Chl

oral

hyd

rate

Chl

oroq

uine

Chl

orpr

omaz

ine

Cilo

staz

ol

Cip

roflo

xaci

n Cital

opra

m

Cla

rith

rom

ycin

Clo

mip

ram

ine

Clo

zapi

ne

Coc

aine

Crizo

tini

b D

abra

feni

b D

asat

inib

D

egar

elix

D

esip

ram

ine

Dex

med

etom

idin

e D

exm

ethy

lphe

nida

te

Dex

troa

mph

etam

ine

(d-A

mph

etam

ine)

D

iphe

nhyd

ram

ine

Dis

opyr

amid

e D

obut

amin

e D

ofet

ilide

D

olas

etro

n D

onep

ezil

Dop

amin

e D

oxep

in

Dro

neda

rone

D

rope

rido

l

28

Med

s th

at p

rolo

ng th

e Q

T in

terv

al

Ephe

drin

e Ep

inep

hrin

e (A

dren

alin

e)

Erib

ulin

mes

ylat

e Er

ythr

omyc

in

Esci

talo

pram

Fa

mot

idin

e Fe

lbam

ate

Fing

olim

od

Flec

aini

de

Fluc

onaz

ole

Fluo

xetine

Fo

rmot

erol

Fo

scar

net

Furo

sem

ide

(Fru

sem

ide)

G

alan

tam

ine

Gem

iflox

acin

G

rani

setr

on

Hal

ofan

trin

e H

alop

erid

ol

Hyd

roch

loro

thia

zide

H

ydro

xych

loro

quin

e H

ydro

xyzi

ne

Ibut

ilide

Ilop

erid

one

Imip

ram

ine

(mel

ipra

min

e)

Inda

pam

ide

Isop

rote

reno

l Is

radi

pine

It

raco

nazo

le

29

Med

s th

at p

rolo

ng th

e Q

T in

terv

al

Ket

ocon

azol

e La

patini

b Le

upro

lide

(Leu

pror

elin

) Le

valb

uter

ol (

levs

albu

tam

ol)

Levo

floxa

cin

Lisd

exam

feta

min

e Li

thiu

m

Met

apro

tere

nol

Met

hado

ne

Met

ham

phet

amin

e (m

etha

mfe

tam

ine)

M

ethy

lphe

nida

te

Met

oclo

pram

ide

Met

roni

dazo

le

Mid

odrine

M

ifepr

isto

ne

Mirab

egro

n M

irta

zapi

ne

Moe

xipr

il/H

CTZ

M

oxifl

oxac

in

Nel

finav

ir

Nic

ardi

pine

N

ilotini

b N

orep

inep

hrin

e (n

orad

rena

line)

N

orflo

xaci

n N

ortr

ipty

line

Oflo

xaci

n O

lanz

apin

e O

ndan

setr

on

Oxy

toci

n 30

Med

s th

at p

rolo

ng th

e Q

T in

terv

al

Palip

erid

one

Pano

bino

stat

Pa

ntop

razo

le

Paro

xetine

Pa

sire

otid

e Pa

zopa

nib

Pent

amid

ine

Perf

lutr

en li

pid

mic

rosp

here

s Ph

ente

rmin

e Ph

enyl

ephr

ine

Phen

ylpr

opan

olam

ine

Pim

ozid

e Po

saco

nazo

le

Proc

aina

mid

e (O

ral o

ff U

S m

kt)

Prom

etha

zine

Pr

opof

ol

Pseu

doep

hedr

ine

Que

tiap

ine

Qui

nidi

ne

Qui

nine

sul

fate

Ran

olaz

ine

Rilp

ivirin

e Ris

perido

ne

Riton

avir

Sal

met

erol

Saq

uina

vir

Ser

tral

ine

Sev

oflu

rane

Sol

ifena

cin

31

Med

s th

at p

rolo

ng th

e Q

T in

terv

al

Tacr

olim

us

Tam

oxife

n Te

lapr

evir

Tela

vanc

in

Telit

hrom

ycin

Te

rbut

alin

e Te

trab

enaz

ine

(Orp

han

drug

in U

S)

Thio

rida

zine

Ti

zani

dine

To

lter

odin

e To

rem

ifene

To

rsem

ide

(Tor

asem

ide)

Tr

azod

one

Trim

etho

prim

-Sul

fam

etho

xazo

le

Trim

ipra

min

e Va

ndet

anib

Va

rden

afil

Vem

uraf

enib

Ve

nlaf

axin

e Vo

rico

nazo

le

Vorino

stat

Zip

rasi

done

159

med

icat

ions

!

Wel

lens

’ Sy

ndro

me

• Sm

all t

erm

inal

inve

rsio

n of

the

T w

ave

in V

1, V

2, V

3

Dr.

Hei

n W

elle

ns

Wel

lens

’ Sy

ndro

me

(a b

road

er d

efini

tion)

• In

vert

ed T

wav

es in

V1,

V2,

V3.

No

loss

of

R w

aves

, No

Qs.

Imm

inen

t cat

astr

ophe

—Yi

kes!

Sign

ifica

nce

of W

elle

ns’ S

yndr

ome

Sign

ifica

nce

of W

elle

ns’

Synd

rom

e

• 75

% c

hanc

e of

mas

sive

ant

erio

r M

I• 

Prox

imal

LA

D le

sion

; (50

% o

f L

V)

• Pt

may

be

pain

-fre

e du

ring

you

r ex

am

and

whi

le th

e E

CG

is b

eing

acq

uire

d.

• R

ecen

t Hx

of c

hest

pai

n or

ang

inal

e

quiv

alen

ts. E

nzym

es m

ay b

e no

rmal

. • 

The

pat

ient

sho

uld

be r

efer

red

to a

ngio

grap

hy

quic

kly

for

PCI

(or

CA

BG

) to

pre

vent

the

MI.

• 

Stre

ss te

st is

fat

al!

95%

occ

lusi

on o

f th

e pr

oxim

al L

AD

Per

cuta

neou

s C

oron

ary

Inte

rven

tion

Art

ery

befo

re s

tent

ing

(red

is lu

men

; ye

llow

is o

bstr

ucti

on)

Aft

er s

tent

ing

Not

e th

e m

uch

larg

er lu

men

The

Spe

ctru

m o

f A

cute

Cor

onar

y Sy

ndro

mes

Hea

lthy

CA

DA

ngin

aU

nsta

ble

Ang

ina

NST

EM

IST

EM

ISh

ock

/ D

eath

Pate

ntar

tery

~50%

~70%

>70

%or

100

%~9

0%10

0%10

0%(o

r va

sosp

asm

)

No

sym

ptom

sPa

in o

n e

xert

ion

Pain

at r

est;

relie

ved

by N

TG

Con

stan

t pai

n39

Rev

iew

!W

PW

: • s

hort

PR

• w

ide

QR

S •

Del

ta w

aves

• ta

chyc

ardi

as •

AF

= s

udde

n de

ath

LG

L: •

sho

rt P

R •

nor

mal

QR

S •

NO

Del

ta

wav

es •

tach

ycar

dias

Bru

gada

: • e

leva

ted

STs

in V

1, V

2, V

3 •

RB

BB

pat

tern

• a

t ris

k fo

r V

T /

VF

Lon

g Q

T: •

QTc

> 4

50

(47

0 )

ms

• at

ris

k fo

r R

on

T =

VT

/ V

F

Wel

lens

: • te

rmin

al T

wav

e in

vers

ion

in

V1,

V2,

V3

• im

pend

ing

mas

sive

MI

144

y.o

. fem

ale

with

his

tory

of

tach

ycar

dia

WP

W (s

hort

PR

, Wid

e Q

RS,

Del

ta w

aves

)

fals

e Q

wav

esde

lta

wav

es

shor

t P

R

130

y.o

. mal

e w

ith r

apid

hea

rt b

eat

2

2L

GL

(sho

rt P

R, n

orm

al Q

RS,

no

Del

ta w

ave)

shor

t P

R

Nar

row

QR

Ss

35 y

.o. m

ale

c/o

epis

odes

of

rapi

d he

art b

eat.

Fath

er d

ied

@ 3

0 y.

o., s

udde

n de

ath.

3

Bru

gada

Syn

drom

e3

RB

BB

, Ele

vate

d ST

Wha

t is

the

Synd

rom

e?(e

xtra

poi

nts

for

the

arrh

ythm

ia!)

4L

ong

QT

inte

rval

4

(Wen

ckeb

ach)

2nd

° A

V B

lock

, Typ

e I D

r. K

arel

Wen

ckeb

ach

Qui

z- W

elle

ns’

synd

rom

e

Wha

t is

the

Synd

rom

e?5

Qui

z- W

elle

ns’

synd

rom

e

Wel

lens

’ Syn

drom

e5

Ele

ctro

lyte

Abn

orm

aliti

es

• H

ypok

alem

ia•

Hyp

erka

lem

ia•

Hyp

erca

lcem

ia•

Hyp

ocal

cem

ia

Pota

ssiu

m e

ffec

ts

• T

he T

wav

e is

a p

otas

sium

eve

nt•

Mor

e po

tass

ium

= t

alle

r T

• L

ess

pota

ssiu

m =

flat

ter

TT

Hyp

okal

emia

• fla

t T w

aves

• la

rge

U w

aves

• lo

ng Q

T in

terv

al

Hyp

okal

emia

Low

, flat

T w

aves

Lon

g Q

T

Pat

ient

on

diur

etic

s. N

ote

the fla

t T w

aves

and

long

QT

inte

rval

.

Hyp

erka

lem

ia

• ta

ll, p

eake

d T

wav

es•

wid

e Q

RS

• no

P w

ave

55

Hyp

erka

lem

ia

Poi

nted

T w

aves

Wid

e Q

RS

• Ta

ll, p

oint

ed T

wav

es•

Los

s of

P w

aves

• W

ide

QR

S

Hyp

erka

lem

ia•

Tall

T w

aves

• W

ide

QR

S•

Los

s of

P w

ave

• C

an le

ad t

o V

T /

VF

Cal

cium

eff

ects

• T

he S

T s

egm

ent

is a

cal

cium

eve

nt•

Mor

e ca

lciu

m =

sho

rter

ST

seg

men

t •

Les

s ca

lciu

m =

long

er S

T s

egm

ent

• C

hang

ing

the

ST s

egm

ent c

hang

es th

e Q

Tc in

terv

al

ST s

egm

ent

Hyp

erca

lcem

ia

Shor

t Q

T in

terv

al. Q

T 3

20 m

s; Q

Tc 3

70 m

s

Cau

sed

by: r

enal

fai

lure

, p

aran

eopl

astic

syn

drom

es,

par

athy

roid

tum

or, M

EN

, oth

ers

59

Hyp

ocal

cem

ia

• L

ong

QTc

inte

rval

• bu

t T w

aves

are

NO

T fla

t (

so it

is n

ot h

ypok

alem

ia)

• m

uscl

e sp

asm

s

60

Prac

tice:

Ele

ctro

lyte

s

61

6W

hat E

lect

roly

te I

mba

lanc

e?

62

Hyp

okal

emia

6

63

7W

hat E

lect

roly

te I

mba

lanc

e?

6464646446464646464

Hyp

erka

lem

ia

7

Tall,

pea

ked

T w

aves

Wid

e Q

RS

• L

oss

of P

wav

es•

Wid

e Q

RS

• Ta

ll, p

oint

ed T

wav

es

No

P w

aves

65556565656565555655555

8W

hat E

lect

roly

te I

mba

lanc

e?

66666666666666666666666

8H

ypoc

alce

mia

Lon

g Q

T in

terv

al, b

ut T

wav

es a

re n

ot fl

at.

67

9W

hat E

lect

roly

te I

mba

lanc

e?H

yper

calc

emia

9

Shor

t Q

T in

terv

al.

Wha

t Rhy

thm

is T

his?

V-T

ach!

Dis

soci

ated

P w

aves

“Fin

ding

the

P is

key

!”

Wra

p it

Up!

Cas

e re

port

:

44 y

.o. m

ale

com

edia

n

c/o

epis

odes

of

rapi

d he

art b

eat.

Goe

s to

em

erge

ncy

depa

rtm

ent.

Wha

t is

the

Synd

rom

e?10

HIP

PA n

ote:

th

is is

not

R

icha

rd P

ryor

’sac

tual

EC

G.

WP

W

shor

t P

R

Wid

e Q

RS

Del

ta w

aves

10B

ut h

e di

d ha

ve W

PW.

75

Why

we

all s

houl

d lo

ve Z

ebrafis

h!

76

Zeb

rafis

h H

eart

Reg

ener

atio

n

77

Zeb

rafis

h H

eart

Reg

ener

atio

n

Zeb

rafis

h

Hum

an

We

shar

e 70

% o

f ou

r ge

nes

wit

h Z

ebrafis

h…

I al

so te

ach…

• A

rrhy

thm

ia in

terp

reta

tion

(SV

Ts, h

eart

blo

cks,

etc

.)

• H

ow t

o sa

y “N

O”

to

Dru

g Se

eker

s

• an

d an

EC

G g

ame:

“T

he R

hyth

m M

etho

d™”

“T

he R

hyth

m M

etho

d™”

jont

ardi

ff@

aol.c

om