This is Basic commonly encountered ecg and concepts

1. D R S Y E D S H A H E E R
F C P S
F E L L O W C A R D I O T H O R A C I C A N E S T H E S I A
I S L A M A B A D
PREOPERATIVE EKG

2. CHAMBER HYPERTROPHY
1. Left atrial Hypertrophy (P-Mitrale)
• Bifid p waves in I, II, avl and avF
• Biphasic p wave in v1
• Mitral stenosis, regurgitation, hypertension,
hypertrophic cardiomyopathy
2. Right atrial enlargement (P-Pulmonale)
• Tall p waves >2mm in II and v1
• Pulmonic stenosis, raised PAP, hypetrophic
cardiomyopathy

4. CHAMBER HYPERTROPHY
3. Left Ventricular Hypertrophy (LVH)
• HTN, AVD, MR, Hypertrophic cardiomyopathy, coarctation
of aorta, myocardial fibrosis
• Cornell criteria (specificity 95%)
Men: S(v3) + R(avL) >28mm
Women: S(v3) + R(avL) >20mm
• Old index
R waves in v5 v6 > 26mm
S waves in v1 v2 >25mm
Sum of R + S > 35mm
• LV Straining: if ST depression and T inversion in lateral chest
leads (secondary ST-T changes)

6. CHAMBER HYPERTROPHY
4. Right Ventricular Hypertrophy (RVH)
• HTN, PHTN, COPD, Transposition, PVS, ASD,
VSD, TR
• Must be pronounced before come to EKG
expression
• Sum of R(v1) + S(v6) >10mm
• Secondary ST-T changes in v1v2 v3
• Mandatory right axis deviation and p-pulmonale is
very common

8. CONDUCTION DEFECTS
5. Right bundle branch block(RBBB)
• QRS > 120ms with M or rSR pattern in v1v2 and
broad S waves in v5 v6 >40ms
• where “r” comes from LV and R comes RV
• Fibrosis, TOF, IHD from LAD, Acute cor pulmonale,
COPD, Previous cardiac surgery, sometimes PCI,
HOCM, Aberrancy, atheletes
• Asymptomatic- no significance
• Dyspnea- suspected pulmonary embolism
• Chest pain- Suspect occlusion of LAD

10. CONDUCTION DEFECTS
6. Left bundle branch block(LBBB)
• Left sided impulses transmitted from right sided branches either
partially or completely
• No Q waves in v5v6
• QRS > 120ms, Broad S waves v1v2, Broad and notched R waves in
v5v6
• Secondary ST-T depressions in v5v6 and elevations in v1v2
• Causes include HTN, LVH, AVD, Myocarditis, IHD, HF,
Cardiomypathies.
• LBBB complicates EKG diagnosis of AMI
a. May imitate acute STEMI- common reason of false
catheterization
b. May conceal ischemia due to disturbance of repolarisation
which usually prevents ST-T changes of ischemia
c. May be caused by ischemia- LBBB mask significant ST-T
changes

11. CONDUCTION DEFECTS
6. Left bundle branch block(LBBB) contd….
• ACC recommends: Patients with clinical suspicion of
ongoing myocardial ischemia and LBBB should be managed
in a similar way to acute STEMI
• Sgarbossa criteria for acute ischemia with LBBB
(specificity 98%)
a. ST elevation >1mm in any (v4v5v6 avL I) – 5points
b. St depression >1mm in any (v1v2v3) – 3 points
c. St elevation >5mm in any (v1v2v3) – 2 points
Cut of points is 3 with high specificity
• Remembrance: Incomplete LBBB with QRS<120ms may
tend to progress to complete bundle branch block.

14. ARRHYTHMIAS
7. Atrial Extrasystoles (PAC)
• Virtually harmless but can proceed to sustained SVTs like A-
fib, AVNRT and AVRT.
• P waves morphology depends on ectopic focus in atria but
PR interval remains static due to regular AV conduction.
• Resetting of SA node so usually no compensatory pause
(Hallmark)
• With sinus tachycardia- may resemble False A-Fib (always
look for p waves)
• Causes include: stress, coffee, smoking, straining of atria.
• Treatment only in feeling excessive palpitations or
tachyarrythmias with Bisoprolol 5-10mg or Ca Channel
blockers.

16. ARRHYTHMIAS
8. Ventricular Extrasystoles (PVCs)
• QRS complex >120ms with compensatory pause
(Hallmark) so increased ventricular filling time
• If 3-30 PVCs occur consecutively, it is called non-
sustanined VT and if 30 or more, it is sustained VT.
• Same morphology- same focus (monomorphic)
• Changing morphology- Polymorphic
• Positive PVCs in v1 – Focus is in left ventricle
• Negative PVCs in v1- Focus is in right ventricle
• Causes include: Males, stress, hypokalemia, infection,
alcohol, sleep deprivation, increasing age, Ischemic
myocardium

18. ARRHYTHMIAS
• For Healthy: If >15% of all beats are PVCs – risk of PVC
induced cardiomyopathy and LV dysfunction – needs ablation
therapy
• For IHD: Treat if
a. Symptomatic – Palpitations
b. > 10 PVCs per minute
c. Negative hemodynamic effects
Rule out: Hypokalemia & Hypomagnesemia
Treat: B Blocker (DOC) Bisoprolol 5-mg OD or metoprolol
50-100mg OD  Amiodarone  Ablation
Remembrance: Watch PVC distance from T wave (R on T
phenomenon)

19. ARRHYTHMIAS
9. Atrial Fibrillation (A-Fib)
• Most common pathological tacharrhythmia
• Risk: Male, HTN, LVH, LVD, any valve disease (Mitral
common), Coronary artery disease, CHF, DM, Obesity,
Smoking, OSAS, COPD.
• Low recurrences: Thyrotoxicosis, alcohol overdosage,
AMI, Pericarditis/Myocarditis, Pulmo embolism
• 5 times risk of stroke and 2 times risk of mortality
specially if LA appendage has a clot
• Long periods of tachy and desynchronised atrial/vent
activity– more adverse effects
• Early anticoagulants reduce risk of stroke by 70%

20. ARRHYTHMIAS
9. A-Fib Contd….
• Absence of p waves and irregularly irregular rhythm (Hallmark),
between QRS complexes are f-waves (300-600/minute). Vent rate
>100/min
• When indoubt apply unilat carotid massage
• Ashmann phenomena frequently associated(abberant vent
conduction in which BBB occurs as result of change in cardiac cycle)
• Types: a. New/Lone A-Fib
b. Paroxysmal-lasts <48hrs
c. Persistent- >7days
d. Long standing - >12months
e. Permanent – Cant be reverted
• Trigger and Driver mechanism—Transition betwn atria and
pulmonary veins is most common trigger and variable excitible
myocytes are common drivers.

22. ARRHYTHMIAS
9. A-Fib Contd….
• Treat: For Acute A-Fib
a. 60% revert spontaneously <16hrs
b. Cardioversion should be performed within 48hrs (>90%
success rate with >200J Biphasic)
c. Chemical cardioversion: Amiodarone, Flecainide, Ibutilide
d. If hemodynamic compromise suspected- electric
cardioversion preferred
• Long Term Treatment:
a. Control Vent rate(Mortality benefit <100/min)
B-Blocker, Ca-Blocker, Digoxin
b. Rhythm Control
Amiodarone, Flecainide, sotalol
c. Ablation therapy

23. ARRHYTHMIAS
• Recent meta-analysis Euro heart journal 2016:
Paroxysmal A fib has lower risk of stroke than persistent
one.
• CHAD scoring for anticoagulation
C= H/O CHF
H= HTN
A= Age >75
D= DM
S= Previous stroke or TIA
Score >3  Significant

24. ISCHEMIA/INFARCTION
Classification of MI by AHA, ACC & ESC:
Type-1:Spontaneous MI
Due to: Plaque rupture, thrombosis, disection
Type-2: MI secondary to ischemic imbalance
Due to: Anemia, Hypo/Hypertension, embolism,
tachy/brady arrhythmias, Resp failure
Type-3: MI resulting in sudden cardiac death
Type-4a: MI secondary to PCI
Type-4b: MI secondary to stent thrombosis
Type-5: Perioperative MI
Due to: CABG

25. NSTEMI
• Subendocardial ischemia, ST depressions, T wave
inversions, elevated troponins and in majority of cases
leads to non Q wave infarction.
• Current guidelines (Nov, 2017 on ESC):
New horizontal or downsloping ST segments
>0.5mm in atleast two anatomically contiguous leads.
• Other causes(frequent)of ST depressions:
Digoxin, Sympathetic stimulation, Hypokalemia,
SVT, Heart failure

27. STEMI
• Transmural ischemia, ST elevations, elevated troponins and
in majority of cases leads to Q wave infarction
• Current guidelines (Nov, 2017 on ESC):
New ST elevations in atleast two anatomically
contiguous leads
Men >40yrs: >2mm in v2v3 & >1mm in all other leads
Men <40yrs: >2.5mm inv2v3 & >1mm in all other leads
Women (any age): >1.5mm in v2v3 & >1mm in all other
leads

29. STEMI
Two areas are normally missed on 12 leads:
a. Posterolateral wall of LV
b. Right Ventrical infarction (v4R and v5R is advised)

31. THANK YOU