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ECG ReviewECG Review
James T. DeVries, MDJames T. DeVries, MD
6 December 20046 December 2004
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45 yo female 1 week post-op with shortness of breath
The most likely diagnosis is:
1) ST elevation MI
2) Digitalis toxicity
3) Pulmonary embolism
4) Ventricular tachycardia
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FindingsFindings
• Accelerated Accelerated junctional rhythmjunctional rhythm
• Right axis deviationRight axis deviation• ““S1Q3T3” patternS1Q3T3” pattern
• Clinical history and Clinical history and EKG most consistent EKG most consistent with acute PEwith acute PE
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67 yo dialysis patient without symptoms
The most likely diagnosis is:
1) Pacemaker malfunction
2) Hyperkalemia
3) Normal EKG for dialysis patient
4) Intermittent LBBB
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FindingsFindings
• NSR with 1rst degree NSR with 1rst degree AVBAVB
• injury current V1-V2injury current V1-V2• Peaked t wavesPeaked t waves• Leftward axisLeftward axis
• Findings most c/wFindings most c/w
hyperkalemiahyperkalemia
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49 yo male with chest pain
This EKG demonstrates
1) acute anterior infarction
2) acute inferior/posterior injury without RV involvement
3) acute inferior/posterior injury with RV involvement
4) acute pericarditis
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FindingsFindings
• Sinus bradySinus brady• inferior STEMIinferior STEMI• posterior STEMIposterior STEMI• V1 ST elevationV1 ST elevation
• Most consistent with Most consistent with inferior/posterior STEMI inferior/posterior STEMI with RV involvementwith RV involvement
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77 yo woman with hypertension
This EKG demonstrates
1) atrial flutter with 3:1 conduction
2) left ventricular hypertrophy
3) no abnormalities
4) left anterior fascicular block
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FindingsFindings
•NSR with 1°AVBNSR with 1°AVB
•LVHLVH
•Best answer is LVHBest answer is LVH
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Criteria for LVHCriteria for LVH
• Sokolow-LyonSokolow-Lyon• Sv1+Rv5/v6>3.5mmSv1+Rv5/v6>3.5mm• RI+SIII>2.5mmRI+SIII>2.5mm• Ravl>11mmRavl>11mm
• CornellCornell• Sv3+Ravl >2.8 (men)Sv3+Ravl >2.8 (men)
>2.0 (women)>2.0 (women)
• Romhilt-EstesRomhilt-Estes• LV strain LV strain 33• LAE LAE 33• LADLAD 22• QRS duration QRS duration 11• R v5/v6>3R v5/v6>3 33• Sv1/v2>3Sv1/v2>3 33• Largest R or S>2Largest R or S>2 33
5 or more points suggests LVH5 or more points suggests LVH
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54 yo female with lung disease and shortness of breath
The rhythm in this EKG is:The rhythm in this EKG is:
1)1) Ectopic atrial rhythmEctopic atrial rhythm
2)2) NSRNSR
3)3) Atrial bigeminyAtrial bigeminy
4)4) Atrial flutter with blockAtrial flutter with block
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FindingsFindings
• Ectopic rhythmEctopic rhythm• Note PR>110msNote PR>110ms• Inverted p wavesInverted p waves
• Best answer: Ectopic Best answer: Ectopic atrial rhythmatrial rhythm
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22 yo male with lightheadedness and palpitation
In addition to an echocardiogram, this patient will likely require:In addition to an echocardiogram, this patient will likely require:
1)1) A permanent pacemakerA permanent pacemaker
2)2) A heart transplantationA heart transplantation
3)3) A coronary angiogramA coronary angiogram
4)4) An ICDAn ICD
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FindingsFindings
• NSR with PAC’sNSR with PAC’s• LVH with repoleLVH with repole
• Hypertrophic cardiomyopathy- altered myocyte Hypertrophic cardiomyopathy- altered myocyte shape, size, and alignment, leading to LVH, shape, size, and alignment, leading to LVH, diastolic dysfunction, and syncope/sudden death. diastolic dysfunction, and syncope/sudden death. Frequently require prophylactic ICD placement Frequently require prophylactic ICD placement when identified.when identified.
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57 yo female with exercise-induced palpitations
This patient presents to your ER with a BP of 100/60. She This patient presents to your ER with a BP of 100/60. She recently had a normal coronary angiogram and echo. The recently had a normal coronary angiogram and echo. The most likely diagnosis is:most likely diagnosis is:
1) Aberrant SVT1) Aberrant SVT
2) VT2) VT
3) Sinus tach with LBBB3) Sinus tach with LBBB
4) Artifact4) Artifact
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FindingsFindings• A/V dissociationA/V dissociation• LBBBLBBB• Rightward axisRightward axis• Positive QRSPositive QRS
axis inferiorlyaxis inferiorly
• RV outflow tract ventricular tachycardia: typically RV outflow tract ventricular tachycardia: typically catacholamine induced (post-exercise), have catacholamine induced (post-exercise), have characteristic LBBB morphology with rightward axis characteristic LBBB morphology with rightward axis and positive QRS vector inferiorly.and positive QRS vector inferiorly.
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25 yo male with systolic murmur
The most likely diagnosis is:The most likely diagnosis is:
1) Congenital bicuspid aortic valve1) Congenital bicuspid aortic valve
2) Severe mitral stenosis2) Severe mitral stenosis
3) Pulmonic stenosis3) Pulmonic stenosis
4) Ebstein’s anomaly4) Ebstein’s anomaly
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FindingsFindings
• RVHRVH• Rightward axisRightward axis
• The constellation of The constellation of right ventricular right ventricular enlargement with enlargement with rightward axis in a rightward axis in a young patient with a young patient with a systolic murmur is most systolic murmur is most suggestive of pulmonic suggestive of pulmonic stenosis.stenosis.
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Quick ReviewQuick Review
• Right axis deviationRight axis deviation• RVHRVH• COPDCOPD• Lateral MILateral MI• LPFBLPFB• Secundum ASDSecundum ASD
• RVHRVH• R>7mm in V1 or R>7mm in V1 or
R>10 with RBBBR>10 with RBBB• Right axisRight axis• S<2 in V1S<2 in V1• qR pattern in V1qR pattern in V1
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32 yo male with palpitations
This ECG demonstrates:This ECG demonstrates:
1) Wandering atrial pacemaker1) Wandering atrial pacemaker
2) Junctional rhythm2) Junctional rhythm
3) Delta waves3) Delta waves
4) Subtle Epsilon waves 4) Subtle Epsilon waves
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FindingsFindings
• NSR withNSR with
short PRshort PR• Delta wavesDelta waves
• WPWWPW
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45 yo male with palpitations
The LEAST likely rhythm is:The LEAST likely rhythm is:
1)1) AVNRTAVNRT
2)2) Atrial flutter with 2:1Atrial flutter with 2:1
3)3) Multifocal atrial tachycardiaMultifocal atrial tachycardia
4)4) Orthodromic atrioventicular tachycardiaOrthodromic atrioventicular tachycardia
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FindingsFindings
• Narrow complex, regular tachycardiaNarrow complex, regular tachycardia• No visible p wavesNo visible p waves
• Multifocal atrial tachycardia requires >3 p Multifocal atrial tachycardia requires >3 p wave morphologies and is slightly irregularwave morphologies and is slightly irregular
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The EndThe End