This document contains 14 cases with ECG findings and questions. It discusses various cardiac conditions that can present with abnormal ECG patterns, including STEMI, arrhythmias, congenital heart defects, electrolyte imbalances, and more. The key takeaways are: lead reversals can change the appearance of STEMI, sinus bradycardia U waves require specific criteria to diagnose hypokalemia, treating hyperkalemia requires membrane stabilizers followed by agents causing potassium influx, tricuspid atresia is the most common cyanotic congenital heart defect, lead issues can cause pacing problems in STEMI patients, inferior MI with RBBB could indicate distant LAD ischemia, mirror imaging limb leads results in a normal E

1. INTERESTING
ECGS
Dr. Nagula Praveen MD, DM
Assistant Professor of Cardiology
Osmania General Hospital
Hyderabad
drpraveennagula@gmail.com
@kizashipraveen

2. Case 1
 A 45 year male, smoker, alcoholic came to ER with chest pain.
 ECG at ER S/O STEMI
 Thrombolysed as lab is occupied
 He had AIVR post thrombolysis
 Shifted to ICCU
 ECG at ICCU…

4. • When reviewed, the ECGs in ICCU and ER are different…

5. At ER

6. At ICCU

8. What might have happened?
A. Lateral wall reinfarction
B. Change in focus of atrial origin from right atrial to left atrial focus after
transient AF
C. Lead reversal RA and LL
D. Lead reversal LA and LL

9. •Lead III becomes inverted.
•Leads I and II switch places.
•Leads aVL and aVF switch
places.
•Lead aVR remains
unchanged.
Lead II
Lead I
Lead -III
Lead AVF
Lead AVL

11. Case 2
 An elderly male 75 years, came with fatigue.
 He is a known hypertensive and Valvular heart disease, has been
recently changed the medications.
 Lab profile was sent which was normal
 His ECG on evaluation showed…

12. A.Digoxin toxicity
B.2:1 AV block
C.Hypokalemia
D.Sinus bradycardia

13. Case 3
 A 65 year male, diabetic, history of CAD bought to ER in
unresponsive state.
 ECG at ER…

14. What is the Immediate action required..?
A. Cardioversion
B. Defibrillation
C. Calcium gluconate bolus followed by insulin
D. Activate cathlab and do Primary PCI

15. ECG9

17. Case 4
21 year female with cyanosis
A. Tricuspid atresia
B. D TGA
C. L TGA
D. DORV

20. Case 5
• A 50 year male hypertensive, diabetic with chest pain.
• He was placed TPI through femoral route for CHB.
• Admission sugars were 200mg/dl
• Immediate profile of electrolytes was normal.
• Post TPI, his ECG

21. What is the likely cause of tall T waves in precordial leads ?
A. Hyperkalemia
B. Ischemia
C. Cerebral T waves
D. None

22. What is the lead position on this ECG?
A. RV Apex
B. RV Mid septum
C. RV Anterior wall or free wall

23. Lead position based on ECG
 Early transition of QRS is mid
septum
 Late transition of QRS in the
precordial leads but before V5,V6
– Free wall (Anterior wall)
 All QRS complexes negatively
concordant , R wave in aVL - RV
Apex
https://doi.org/10.1093/eurheartj/suaa094

25. What would be the probable cause of undersensing asynchronous pacing in this ECG ?
A. Lead fracture B. Infarction C. Electrolyte imbalance D. Magnet applied

26. Case 6
 A 56 year male diabetic, smoker, previous history of CAD came
with chest pain
 ECG at ER

27. What is unusual finding in this ECG?
A. ST elevations and depression not classical of STEMI B. First degree AV block mimicking CHB
C. RBBB D. Lateral extension of infarct

28. ECG6

31. Case 7
A 35 year male, with congenital heart defect (no intracardiac
lesions) complains of SOB
• A.
A. LA RA Lead reversal, normal precordial leads, patient is having levocardia
B. LA RA Lead reversal, normal precordial leads, patient is having dextrocardia
C. Normal limb, normal precordial leads, patient is having dextrocardia
D. LA RA lead reversal , right sided precordial leads with dextrocardia

32. If you don’t reverse limb leads LA RA
AVL will behave as AVR
Axis will be towards Lead III (+120)
“which is same as towards lead II in normal heart”
If you totally reverse the limb leads (mirror image) then the ECG will be as normal

35. Case 8
A. 2 :1 AV block
B. Complete Heart block
C. Mobitz type I AV block
D. Sinus pause

37. Case 9
ECG diagnosis is
A. Anterolateral STEMI with Precordial leads misplacement
B. Extensive Anterior wall MI
C. Extensive Anterior wall STEMI with precordial leads misplacement

38. Case 10

39. Case 11
What is the unsual in this ECG of this patient with no comorbidities, presenting with chest
pain considering a single diagnosis ?
A. Pericarditis
B. Bradycardia
C. It can be STEMI
D. Early repolarization variant

40. Case 12
A 65 year female with seizure disorder had TLOC and presented to ER,
ECG showed
A. Cerebral T waves
B. CHB with T waves secondary
to stoke adams episode
C. Ischemia
D. HCM

42. • Giant T wave inversions indicate VF as cause of loss of
consciousness than standstill.

44. Case 13
Elderly hypertensive with giddiness
A. Sinus bradycardia with junctional escape rhythm, isorhythmic dissociation
B. Type II Sino atrial exit block
C. Complete heart block
D. Type II Mobitz AV block

46. Case 14 Young female
A. Pericarditis
B. Early repolarization variant
C. STEMI
D. Brugada syndrome

47. Case 15
A 28 year male, recent COVID, came for
evaluation of cardiac function post recovery
A. Pericarditis
B. Early repolarization variant
C. STEMI
D. Hyperkalemia

49. Take Home Message
1. Lead reversal can change the culprit artery in STEMI.
2. Sinus bradycardia can result in u waves, not be mistaken for hypokalemia unless the
amplitude of U wave being more than T wave and having ST depression.
3. It is important to give membrane stabilizer calcium in a patient with hyperkalemia
followed by agents causing influx of potassium.
4. Cyanotic CHD with LAD,LV volume overload – tricuspid atresia is the most common.
5. Loss of capture, undersensing can be encountered in STEMI patient being kept on
TPI.
6. Inferior wall MI with RBBB,RAD – suspect distant ischemia in LAD.
7. Change of limb leads, precordial leads ( mirror image) – would result in normal ECG
in a patient with dextrocardia.
8. When P marches through QRS and not married – suspect CHB.
9. Stoke Adams syndrome is an important cause of deep T wave inversions
10. Early repolarization variant, is not a benign condition, it has considerable risk of SCD
.

50. THANK YOU