Ekg Cases Jul09.Level One Part 1


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Ekg Cases Jul09.Level One Part 1

  1. 1. Case-oriented EKG’s (level 1- easiest) MDFPR July 1, 2009 M. LaCombe
  2. 2. The normal EKG waveform
  3. 3. A normal EKG
  4. 4. The frontal plane (QRS) axis:
  5. 5. Case#1: The patient is a 47-yr-old female who is asymptomatic with the following ECG finding reportedly since birth.
  6. 6. The tracing shows sinus rhythm with complete heart block and an A-V junctional type escape rhythm. The P-P interval surrounding an individual QRS complex is narrower (shorter) than the P-P interval between two QRS complexes. Sinus rate variation with complete heart block is called ventriculophasic sinus arrhythmia. The patient has congenital complete heart block. This entity is usually idiopathic but may be secondary to placental transfer of anti-Ro and La antibodies from the mother. The spectrum of disease ranges from patients who are born with severe bradycardia and require pacemakers in infancy to patients who live full life spans without artificial pacemakers. The overall infant mortality is 15%. The escape rhythm in this instance is proximal in the conduction system and a pacemaker is not required at this time.
  7. 7. Case #2: 34-year-old male. What's going on here?
  8. 8. ECG shows classic findings of acute/hyperacute anterior wall Q wave myocardial infarction (MI), with reciprocal inferior ST depressions. The distribution of changes is consistent with a proximal left anterior descending (LAD) occlusion which was confirmed at cardiac catheterization and treated with angioplasty/stent. Premature atherosclerosis here was associated with multiple risk factors for coronary artery disease:hypertension, hyperlipidemia, family history and tobacco.
  9. 9. Case #3: 47-yr-old male. What is the diagnosis? What should you do?
  10. 10. Acute anterior wall myocardial infarction (MI) ST-elevation (STEMI), consistent with proximal left anterior descending (LAD) occlusion, with Q waves (V1-V3) and ST elevations (V1-V5). Page interventional cardiology, stat! Emergency Treatment: aspirin, beta-blocker, nitroglycerin, morphine, etc, unless specific contraindications exist, with plans for immediate reperfusion therapy. See: J Am Coll Cardiol 2004;44:671-719.
  11. 11. Case #4: 64-year-old male with chest pain. What vessel was acutely occluded at catheterization?
  12. 12. The left anterior descending (LAD). The patient actually had multivessel disease. The ECG shows an extensive acute/evolving antero- lateral myocardial infarction (MI) pattern. The rhythm is borderline sinus tachycardia with a single premature atrial complex (PAC)-(4th beat). Note also low limb lead voltage and probable left atrial abnormality (LAA). Left ventriculography showed diffuse hypokinesis as well as akinesis of the antero-lateral and apical walls, with an ejection fraction of 33%.
  13. 13. Left anterior oblique caudal angiographic projection demonstrating total occlusion of the proximal left anterior descending artery (open arrow). Also noted is ramus intermedius disease (closed arrow) as well as circumflex system disease (small arrows).
  14. 14. Transthoracic apical four-chamber echocardiographic image demonstrating antero-septal and apical aneurysmal dilation (arrows) of the left ventricle (LV) post-LAD infarct. LA = left atrium; RV = right ventricle; RA = right atrium.
  15. 15. Dual isotope stress (top rows) and rest (bottom rows) images demonstrating fixed distal anteroseptal (straight white arrows) and infero-basal (angled arrows) perfusion defects. Note both defects are seen in multiple views. Short axis (SA) images are arranged from apex to base; vertical long axis (VLA) images are arranged from septum to lateral wall; and horizontal long axis (HLA) images are arranged from inferior to anterior.
  16. 16. Case #5: 26-year-old man prior to enrolling in anti- convulsive medication trial. Are there any abnormalities?
  17. 17. No. Within normal limits. Precordial voltage is prominent but within normal range, especially in young adults, without left atrial abnormality or ST-T changes of left ventricular hypertrophy.
  18. 18. Case #6: Why is this young cocaine abuser in the emergency department?
  19. 19. He is having an evolving anteroseptal myocardial infarction secondary to cocaine. There are Q waves in V2-V3 with ST segment elevation in V2-V5 associated with T-wave inversion. Also noted are biphasic T-waves in the inferior leads. These multiple abnormalities suggest occlusion of a large left anterior descending (LAD) artery that wraps around the apex of the heart (or multivessel coronary artery disease).
  20. 20. Left anterior oblique caudal angiographic projection demonstrating total occlusion of the mid-LAD (open arrow) distal to the takeoff of a large first diagonal branch. Also noted is a 90% tubular stenosis of the first obtuse marginal branch (closed arrow).
  21. 21. Rest thallium images showing antero-apical perfusion defect (arrows), which appears as an area of decreased tracer counts. Vertical long axis (VLA) slices are arranged from septum to lateral wall. Horizontal long axis (HLA) images are arranged from inferior wall to anterior wall. Short axis (SA) images are arranged from apex to base. Image shows apex centrally, out to base on the periphery
  22. 22. Case #7: What is the EKG diagnosis in this 48- y.o. man? • Early repolarization (normal variant) • Acute pericarditis • Acute anterior wall STEMI • Hyperkalemia • Systemic hypothermia with Osborn waves
  23. 23. •Early repolarization (normal variant) •Acute pericarditis •Acute anterior wall STEMI •Hyperkalemia •Systemic hypothermia with Osborn waves
  24. 24. c) Acute anterior wall ST elevation MI (STEMI) Note the marked ST elevations and hyperacute T waves in the anterior/lateral leads, including V2-V5, I and aVL. Slight reciprocal ST sagging/depression is present in lead III. There is decreased R wave progression in lead V2, consistent with an acute myocardia infarction (MI) as well. The patient had sustained an occlusion of the proximal left anterior descending coronary artery.
  25. 25. Aside: Osborn Waves or J waves seen in hypothermia
  26. 26. Segue: Famous People Who Died Young, from Coronary Disease
  27. 27. Jim F Fixx 1932 - 1984, 52-year-old Jim Fixx collapsed while out jogging July 20, 1984 and died of a massive heart attack. Autopsy revealed extensive heart disease with coronary artery blockages of 99%, 80%, and 70%. Jim took up running in the 1960's when he weighed 220 lbs. He is credited with helping start America's fitness revolution, popularizing the sport of running. His best-selling book, 'The Complete Book of Running' was published in 1977 and sold over 1 million copies. By that time he was jogging an average of 60 miles every week and his weight was down to 159lbs. In 1980 he published Jim Fixx's 'Second Book of Running: The Companion Volume to The Complete Book of Running'. Jim's father died of a heart attack at age 43 and Jim's cholesterol levels was above 250 mg/dl. He was survived by four children.
  28. 28. Darryl Kile 1968 - 2002, the St Louis Cardinal pitcher complained to his brother Daniel of shoulder pain and weakness Friday June 22, 2002, the night before he died, possible warning signs that he had heart problems. Kile was found dead Saturday in his 11th-floor hotel room at the Westin Hotel after he failed to show up for St. Louis' game against the Cubs. The night before, he had gone to dinner with his brother, Daniel. Daniel reported that Darryl said his shoulder was hurting and that he felt weak but "For a guy who was a pitcher in the major leagues, (the weakness) was an unusual symptom" . Kile's father died from a heart attack in his mid-40s.An autopsy on Kile, 33, revealed an 80 to 90 percent narrowing of two of his three coronary arteries, said Dr. Edmund Donoghue, the Cook County medical examiner. Cardinals spokesman Brad Hainje said Kile had a physical examination during spring training. He said he was not aware of Kile complaining of chest pains.
  29. 29. Brian Maxwell 1953 - 2004, collapsed Friday March 19, 2004 at a post office, and died of a heart attack. He was 51. In 1977 Maxwell was ranked the No. 3 marathon runner in the world by Track and Field News. Maxwell and his wife Jennifer, a nutritionist, co-founded PowerBar, the popular energy bar company in 1986 and began by selling PowerBars out of their kitchen. Over the next decade, the Berkeley, California-based firm grew to $150 million in sales and 300 employees. In March 2000, the couple sold the company to Nestle SA for a reported $375 million. Maxwell is survived by his wife and five children
  30. 30. Robert Palmer 1949 - 2003, the British rock singer died suddenly of a heart attack at age 54 at the luxury Paris Warwick Hotel on September 25th after a calm night of dinner and a movie. The singer had received a clean bill of health from his doctors in Switzerland just a few weeks earlier. Palmer began his career at the age of 19 singing with the Alan Bown Set and a soul group, Vinegar Joe, before going solo in 1974. He became known for slick videos and a clever combination of rock, R&B and reggae sounds with hit singles including "Simply Irresistible", "I Didn't Mean to Turn You On", and the Grammy winning "Addicted to Love". The "Addicted to Love" video, featuring a sharply dressed Palmer flanked by miniskirted models, became one of early MTV's most-played clips. Palmer is survived by his companion of 20 years Mary Ambrose and two children
  31. 31. Miguel Contreras 1953 - 2005, the son of migrant farmworkers who grew to be one of the nation's most powerful urban labor leaders was stricken by a sudden heart attack on the way to a meeting on Friday May 6. Contreras began working the fields of California's fertile Central Valley at age 5. By age 17, he was leafleting supermarkets on behalf of the national grape boycott called by Cesar Chavez's then-fledgling United Farm Workers of America. He joined the Los Angeles County Federation of Labor in 1993. In 2000, he helped lead a strike by Los Angeles janitors, many of them poor immigrants, against building owners. The work stoppage ended with a new contract that was touted as a model for labor organizations across the country. That year he also played a key behind- the-scenes role in resolving the Los Angeles County transit strike that paralyzed public transportation for over a month. At one point, he publicly rejected what the Metropolitan Transportation Authority had characterized as its final offer, calling it "cheap" and denouncing it as an attack on "core middle class jobs." Later, he brought in the Rev. Jesse Jackson as a mediator when it appeared negotiations had broken down. At the time of his death, Contreras was leader of the L.A. County Federation of Labor, AFL-CIO, an umbrella organization representing 345 local unions with political clout extending from Los Angeles to the state Capital and beyond. Contreras is survived by his wife, fellow labor organizer Maria Elena Durazo, and two sons, Michael and Mario.
  32. 32. Case #8: What arrhythmia is present in this elderly woman with a history of mitral valve replacement for rheumatic mitral valve disease? • Atrial flutter • Atrial fibrillation • Junctional rhythm • NSR with frequent APC’s • MAT
  33. 33. •Atrial flutter •Atrial fibrillation •Junctional rhythm •NSR with frequent APC’s •MAT
  34. 34. b) The patient had long standing atrial fibrillation. There are no discrete P waves which excludes sinus rhythm or multifocal atrial tachycardia. The erratic irregular oscullatory baseline with an erratic ventricular response is typical of atrial fibrillation. No flutter waves are seen. The scooping of the ST-T waves in the inferolateral leads are consistent with digitalis effect.
  35. 35. Case #9: Which of the following statements about this EKG from a 23 y.o. woman with chest pain is correct? • The EKG is normal • It shows RVH • It shows LVH • It suggests severe hypokalemia • It suggests severe hypocalcemia
  36. 36. •The EKG is normal •It shows RVH •It shows LVH •It suggests severe hypokalemia •It suggests severe hypocalcemia
  37. 37. a) The ECG shows sinus rhythm at a rate of about 60/min and is completely within normal limits. The electrical axis (about +50 degrees) and basic intervals (PR, QRS and QT) are all normal. The P waves are normal. The QRS complexes have a normal morphology. The precordial leads show normal R wave progression (transition zone between V2 and V3). The ventricular repolarization (ST-T complex) is physiologic (with a normal QT interval) making severe hypokalemia or hypocalcemia unlikely. Severe hypokalemia generally causes repolarization (QT-U) prolongation (usually with flat T waves and sometimes ST sagging). Severe hypocalcemia prolongs the plateau phase of the ventricular action potential, associated QT prolongation due to a stretched out ST segment.
  38. 38. Case #10 A 78-year-old man was brought to the Emergency Department. His wife noted that he had a fever and was more difficult to rouse this morning. All of the following statements about his ECG are true EXCEPT: a) The rhythm is sinus tachycardia b) The PR interval is borderline prolonged c) There is a complete left bundle branch block d) There is left atrial abnormality e) There is borderline low voltage in the limb leads
  39. 39. The rhythm is sinus tachycardia b) The PR interval is borderline prolonged c) There is a complete left bundle branch block d) There is left atrial abnormality e) There is borderline low voltage in the limb leads
  40. 40. The rate is approximately 100 beats per minute, and there are upright P waves in lead II, fulfilling the criteria for sinus tachycardia. The PR interval is slightly prolonged at 0.21 second (normal PR < 0.20 second), especially in light of the patient’s tachycardia. The P wave is also wide in lead II (normal duration <0.12 second) and has a large negative component in lead V1 (normal depth <1 mm and width < 0.04 second). These characteristics indicate left atrial abnormality (LAA.) The QRS voltage in the limb leads just meets the criteria for low voltage (< 5 mm in all limb leads). There is no left bundle branch block (LBBB.) The criteria for complete LBBB include:1. QRS duration > 0.12 second2. A wide deep QS complex in V1-3 and a wide tall R wave in V6.
  41. 41. Additional comments: Even a mild sinus tachycardia at rest, especially in an elderly individual, may signal a major abnormality. Generally, sinus tachycardia results from conditions that either increase sympathetic tone or decrease vagal tone. Here is a partial differential diagnosis for resting sinus tachycardia. Can you think of other causes? 1. Fever, infection, septic shock 2. Volume depletion (blood loss, dehydration, pancreatitis, diarrhea, vomiting) 3. Anxiety, pain, excitement 4. Endocrine disorders (hyperthyroidism, pheochromocytoma) 5. Anemia 6. Pulmonary embolism 7. Acute myocardial infarction with pump dysfunction 8. Stimulants, such as nicotine, caffeine, cocaine, ecstasy, methamphetamine, ephedra, and some antidepressants 9. Anticholinergics, such as atropine This patient was diagnosed with a urinary tract infection and treated with antibiotics.
  42. 42. Important! Never ignore a sign, symptom, or lab test you can’t explain.
  43. 43. Case #11 A 21-year-old man presents to the Emergency Department after having a witnessed seizure. All of the following statements about this ECG are true EXCEPT: a) The QRS axis is within normal limits b) The rhythm is sinus tachycardia c) The QT interval is normal for the rate d) There is no evidence of left ventricular hypertrophy e) There is a complete right bundle branch block
  44. 44. a) The QRS axis is within normal limits b) The rhythm is sinus tachycardia c) The QT interval is normal for the rate d) There is no evidence of left ventricular hypertrophy e) There is a complete right bundle branch block
  45. 45. e)   There is a complete right bundle branch block The QRS axis is normal at approximately +70 The rate is approximately 110 beats per minute, and there are upright P waves in lead II, fulfilling the criteria for sinus tachycardia. The QTc interval is normal at 0.37 second (normal QTc < 0.44 second). There is no ECG evidence of left ventricular hypertrophy (LVH), such as prominent voltage in the chest leads, T wave inversions in leads with tall R waves, left axis deviation, left atrial abnormality, or a left ventricular conduction delay. There is no right bundle branch block (RBBB.) The criteria for complete RBBB include:1. QRS duration > 0.12 second2. In V1, an rSR complex with a wide terminal R wave3. In V6, a qRS complex with a wide S wave
  46. 46. Additional comments: Changes in heart rate have long been noted to occur during seizures, both partial and generalized. While sinus bradycardia and even sinus arrest have been described infrequently, sinus tachycardia is a common occurrence during seizure activity. Other rhythm abnormalities have also been reported, though rarely, and include atrial and ventricular premature depolarizations, atrial fibrillation, and torsade de pointes.
  47. 47. Case #12 A 67-year-old man is admitted to the hospital for a large abscess in his lower abdomen with surrounding cellulitis. Which of the following statements about his admission ECG is (are) correct: a) The rhythm is sinus tachycardia b) There is right axis deviation c) There is a complete right bundle branch block d) a and c e) All of the above
  48. 48. a) The rhythm is sinus tachycardia b) There is right axis deviation c) There is a complete right bundle branch block d) a and c e) All of the above
  49. 49. d) a and c The rate is approximately 100 beats per minute, and there are upright P waves in lead II, fulfilling the criteria for sinus tachycardia. His tachycardia is likely related to pain and to his infection. The QRS axis is -15 borderline left axis. Frank left axis deviation is usually defined by an axis between -30 and -90 Finally, there is a complete right bundle branch block (RBBB). The criteria for complete RBBB include: 1. QRS duration > 0.12 second 2. In V1, an rSR’ complex with a wide terminal R wave 3. In V6, a qRS complex with a wide S wave
  50. 50. Additional comments:RBBB may be seen in normal hearts but is usually associated with an underlying pathology. Conditions such as Chronic Obstructive Pulmonary Disease (COPD), pulmonary hypertension, atrial septal defect (ASD), or pulmonic stenosis may, in the long run, result in RBBB because of the hypertrophy that occurs in response to pressure or volume overloads. The conduction systems of aging hearts may also undergo degenerative changes, causing RBBB in the absence of any other pathology. Occlusion of the left anterior descending artery (LAD), causing an acute anterior myocardial infarction, can also cause RBBB because the LAD typically supplies the proximal right bundle. The lesions causing RBBB typically occur in the proximal right bundle, though they can also occur at the level of the moderator band and in the terminal portion of the right bundle.Also note the T wave inversions in leads V1 and V2. T wave inversions in leads with tall R waves are typical in RBBB and are called secondary changes. Since depolarization of the right ventricle is delayed with RBBB, repolarization is delayed as well. This altered sequence changes the direction of the repolarization vector, resulting in T wave inversions in leads with terminal R waves. In contrast, primary T wave abnormalities reflect an intrinsic disturbance of the action potentials, which may occur with ischemia, electrolyte abnormalities, or drug toxicity.This patient had his abscess drained under anesthesia. His cellulitis was treated with antibiotics and improved.
  51. 51. Aside: Who invented the EKG machine anyway?
  52. 52. Willem Einthoven
  53. 53. Willem Einthoven was born on May 21, 1860 in the city of Semarang on the island of Java in Indonesia. His father was a physician, but died when Willem was only a child. After his father's death, his mother moved back to the Netherlands with young Willem. In 1870, the family settled in the city of Utrecht, where Willem finished his education. In 1885, he earned a medical degree from the University of Utrecht and was given a position as a professor at the University of Leiden in 1886. When he wasn't teaching, he spent a lot of time researching various medical inventions. At that time, doctors knew that the heart produced electrical impulses. However, the electronic equipment did not exist to accurately measure the heart rate or view the amplitude of the electrical impulses. In 1901, Einthoven sought to solve this problem using a rather crude method. Einthoven's method for measuring the waveform of the heart used a "string galvanometer". Essentially it used a thin conductive wire, which ran between two electromagnets. The wire was connected to electrodes on the patient's chest and would move between the electromagnets when a current passed through it (indicating a heartbeat). By shining a light on the wire and placing photographic film underneath the wire, Einthoven was able to record a curve showing the amplitude of the patient's heartbeat. While Einthoven's machine was very crude, it was able to record the same signal that we see today using modern heart monitors. His machine required five people to run it and weighed in at six hundred pounds. He called it the electrocardiogram (ECG/EKG). In addition to inventing the machine, Einthoven also named the traditional deflections of a normal ECG waveform, using the letters P, Q, R, S, and T. He also contributed to the medical field by measuring the waveforms produced by various cardiovascular disorders. These irregular rhythms have since become known as arrhythmia and modern devices are able to automatically detect such conditions. In 1924, Einthoven was awarded the Nobel Prize in Medicine for his invention of the ECG machine. Einthoven died on September 29, 1927 in the city of Leiden.
  54. 54. Snap Quiz: What famous French novelist was born on this day in 1804? Hints: she took a male pseudonym, had affairs with Alfred de Musset (who had aortic regurgitation and hence de Musset’s sign) and with Chopin.
  55. 55. George Sand
  56. 56. Please remember, Jeopardy looms in late August…