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John C. Evans, MD Fellow Division of Cardiovascular Medicine Oregon Health and Science University 9/25/07
Disclaimer
Some of these slides were made using images found on the web. In particular ABC of Electrocardiography by Morris and Brady from the British Medical Journal. Please use the web to track down the images and use the respective pages. Dont rat Dr. Luft out to the publishers. If you are a publisher, dont sue me; its Dr. Luft.
Lecture Topics:
Lecture 1
Introductory Approach to ECG Interpretation
Lecture 2
Introduction to Rhythm Analysis
Lecture 3
Introduction to clinical ECG changes/Ischemia
ECGinterpretation
identification standardization rate rhythm axis intervals voltage/chambers/hypertrophy geography/ischemia/infarction
Bradycardia
Sinus bradycardia Sinus arrest with subsidiary pacemaker
Ectopic atrial Junctional Ventricular
Block
Second degree Type I (Wenckebach) Second degree Type II Complete Heart Block
Bradycardia Algorithm
Regular? AV dissociation?
If AV dissociated
And A>V: heart block And V>A: ventricular pacemaker
How irregular?
Irregularly Irregular
Atrial Fibrillation
Wandering Pacemaker
Grouped
Second Degree Block
Tachycardia
Wide Complex
Ventricular Tach SVT w/ aberrancy -preexisting -rate-related -AVRT
Narrow Complex
Regular Sinus Tach Atrial Flutter AV Reentry Tach AVN Reentry Tach Atrial Tach Junctional Tach Irregular Atrial Fib Multifocal AT Variable Conduction
Anatomy
Anatomy
Lead Localization
R wave progression
Normally
No q anteriorly R:S should increase until V5 R:S should be 1:2 by V3 and 1:1 by V4 Septal q laterally
Plaque Rupture
STEMI Evolution
Hyper acute T waves - minutes ST elevation (Injury/Acute MI) hours Deep Q waves with ST elevation (Recent MI) - days Q waves with T wave inversion (Age indeterminant) - weeks Q wave with normalization of T wave (Old) - months
ST Elevation
The ST segment elevation may fuse with the QRS and T wave - yielding a Tombstone complex.
Reciprocal ST Depression
ST depression often develops at in leads opposite the sight of infarction. Known as reciprocal depression. Can be helpful to confirm STEMI. May represent mirror image phenomenon.
ST elevations
Reciprocal depressions
Reciprocal depression
ST elevation
Q waves are considered significant or pathological if they are > 30msec wide and/or > 1/4 of the R wave amplitude. Q waves in III and aVR can be normal (even if significant). Look for an anatomic pattern!
ST elevations
Reciprocal depressions
Lateral Infarct
Inferior/Posterior Infarct
Complications of STEMI
Complications can include: pericarditis, CHF, VSD, papillary muscle rupture (acute MR), aneurysm formation, thrombus, and LV rupture.
LV rupture
LV aneurysm
ST Segment Elevation
Causes of ST segment elevation
Acute myocardial infarction Benign early repolarization Left bundle branch block Left ventricular hypertrophy Ventricular aneurysm Coronary vasospasm/Printzmetal's angina Pericarditis Brugada syndrome Subarachnoid haemorrhage
Pericarditis
Pericarditis
ST Segment Elevation
PR Depression
Early Repolarization
Early Repolarization
Vasospasm
Baseline
Spasm
Spasm Resolving
ST Elevation in LBBB
Up to 5mm of discordant ST elevation may be normal.
Infarction in LBBB
Note >5mm discordant elevation in V2-V4. Note > 1mm concordant ST elevation in V5 and V6. This may represent acute infarction.
T waves
Different T wave morphologies can represent ischemia. T wave abnormalities can also reflect normal variation, youth, electrolyte abnormalities, drugs, CNS abnormalities, lead misplacement, etc. T waves should generally be <10mm tall and be approximately >1/8 the height of the R wave. T wave inversion in III, aVR and V1 may be normal. T wave inversion V1-V3 seen in juvenile pattern.
T Waves (biphasic)
Biphasic T waves are frequently associated with ischemia and acute coronary syndrome. Usually seen in V1-V3. Correlate with LAD disease. Sometimes referred to as Wellens waves.
T waves
Tall T waves (> 10mm) may represent ischemia.
T waves
T waves (non-specific)
T waves
ST Depression
ST segment depression may also represent ischemia. Like T wave inversions and ST elevations, it is not specific to ischemia.
ST Depression
Note deep, downsloping ST depressions. High probability of ischemia (espically if new or associated with chest pain).
ST Depression (LVH)
Hyperkalemia
Elevated K+ can result in deadly rhythms. The typical progression of EKG change with rising potassium is roughly: Peak T waves (tall) K+>6 QRS widening and P flattening K+>7 Sinusodial tachycardia K+>8
1. 2. 3.
Hyperkalemia (Sinusodial)
Hypo/hypercalcemia Hypo/hypermagnesemia
Back to axis
Left axis deviation
LAFB LVH IMI AMI
So much more
Blocks
Block above and below the AV node Complete heart block with a-fib
Syndromes
Lown-Ganong-Levine Brugada ARVD Short QT
So remember.
ECGinterpretation
identification standardization rate rhythm axis intervals voltage/chambers/hypertrophy geography/ischemia/infarction
Thank you
Dr. Luft for his slides Ryan Palmer for all his help The facilitators of the small groups You (questions AND feedback are greatly appreciated)