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ECG: Atrial Bigeminy with deep inverted T waves

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    ECG: Atrial Bigeminy with deep inverted T waves ECG: Atrial Bigeminy with deep inverted T waves Presentation Transcript

    • ECG of the Week!!!
      Dr. K. Manoj Kumar
      Prof. Dr.Gowrishankar Unit
    • A 55yr old Male, c/o shortness of breath – 7 days; chest pain – 6days
      No h/o syncope ; no h/o oliguria; no h/o fatigue
      Not a known Diabetic; known hypertensive for 5yrs
      No h/o similar illness in the family
    • O/E Patient Conscious
      Mildly dyspneic,tachypneic
      Mild pallor – I0/PE0/L0/CL0
      CVS S1 S2+ S4+; systolic murmur+ not radiating to carotid
      RS NVBS heard
      P/A soft
      BP 130/80 mm hg
      PR 76/min
    • On Investigation
      Blood Sugar, Urea Creatinine levels are within normal limits
      CBC with normal limits
      Chest X-Ray
      Mild cardiomegaly
      Lung fields clear
    • ECG
    • ECG shows:
      Rate : 75/min
      Normal axis of 15 degree
      Normal ST segment
      PR interval normal
      normal sinus beat followed by atrial ectopic
      Atrialbigeminal rhythm
      Tall R waves with deep symmetrical sharply pointed inverted T waves in the mid precordial leads
      The initial horizontality of ST Segment with well developed ST T angle – ST Segment shelf is seen
    • Differential Diagnosis of this ECG
      Hypertrophic cardiomyopathy
      lV SYSTOLIC OVERLOAD like hypertension
      Myocardial ischemia
      CVA with qrsst pattern
      Valvular aortic stenosis
    • Hypertrophic Cardiomyopathy
      Inheritable autosomal dominant disease of heart muscle d/tmutation in beta mhc of chr14
      characterized by thickened but non dilated left ventricle in the absence of another cardiac or systemic condition capable of producing magnitude of the hypertrophy evident
      Small ventricular cavity and marked hypertrophy of myocardium with myofibril disarray w/wo dynamic outflow tract obstruction
    • Most common cause of sudden cardiac death in young people including trained athelets
      WHO designated with HCM to describe this unique process of primary muscle hypertrophy
      M mode echo define ASH
      Myocardial disarray of muscle fibre result in WHORLING characteristic of HCM
    • Pathophysiology
      Diastolic dysfunction
      LV Out flow tract obstruction
      Mitral regurgitation due to elongated mitral leaflets and chordae
      Intramyocardialischaemia due to partially obliterated intra mural coronary arteries
      Arrythymias
      Autonomic dysfunction – systolic BP↓ on exercise
    • EFFECT OF MANEUVER FOR HCM DIFFERENTIATION
      MANEUVER PHYSIOL EFFECT HCM AS MR Valsalvavr,svr,co
      squat&handvr,svr,co
      Grip &phenyl ephrine
      Amylnitritevr, decsvr
    • Parameters associated with sudden death
      survivor of cardiac arrest
      Sustained VT
      Family history of premature sudden death
      Massive degree of ventricular hypertrophy
      Hypotensive response to exercise
      Myocardial bridging
      Septal thickness > 30mm
      Troponin t mutation
      Courtesy Braunwald heart diseases & Harrison Medicine
    • Echo Findings
      LV hypertrophy with septum >1.3times posterior LV wall thickness
      Ground glass appearance of septum
      Spade shaped LV Cavity
      small lv cavity
      SAM of mitral valve
      septal immobility
      premature closure of aortic valve
      resting gradient>30mm
      provocable gradient>50mm
    • ECHO CLASS OF LVH IN HOCM
      TYPE 1 ..ANT SEPTUM 10%
      TYPE 2…ANT AND POST SEPTUM 20%
      TYPE 3 ..ANT AND POST SEPTUM INCLUDING LAT.FREE WALL 52%
      TYPE 4 ..REGION OTHER THAN SEPTUM AND POST FREE WALL 18%
    • Complications
      Sudden death
      Infective endocarditis
      Systemic embolism
      Atrial fibrillation
      High incidence of SVT 46%, PVC 43%, VT 26% AF 25-30%
    • Treatment
      Screening Echo for first degree relatives
      Avoid strenuous exercise
      IE prophylaxis
      Keep well hydrated
      Medical therapy like Beta blockers, calcium channel blockers, diisopyramide
      Surgical options include septalmyectomy. Dual chamber pacing, septal ablation in patients not responding to surgery
      AICD for prevention of sudden death
    • Thank u