ecg intensive

ECG

Dr Andey bin Rahman

Case 1

• 19/m/male, cough with pricking chest pain

BER

– Widespread concave ST elevation, most prominent in the mid- to left precordial leads (V2-5)

– Notching or slurring at the J-point

– Prominent, slightly asymmetrical T-waves

– No reciprocal

Case 2

• 40/lady found unconscious

STE @aVR

• Lead aVR is a very interesting lead in the ECG. aVR obtain information from the

1) right upper portion of the heart, including the outflow tract of the right ventricle and the basal portion of the septum

2) reciprocal information as to that which is derived from leads aVL, II, V5, and V6

Important findings in aVR includes1)ST-segment elevation as an indicator of significant left main

coronary artery(LMCA) involvement in acute coronary syndromes

2)PR-segment elevation in acute cases of pericarditis3)R' wave in tricyclic antidepressant (TCA) poisoning

STE @aVR

• STE in aVR indicate1)Reciprocal STD from leads aVL, II, V5, and V6Due to diffuse subendocardial ischemia indicates severe 3VD- STE in aVR with diffuse STD in other leads usually more than 8 surface

leads

2)Theoretically infarction of the right upper portion of the heart, including the outflow tract of the right ventricle and the basal portion of the septum

The basal septum is supplied by the first septal perforator artery (a very proximal branch of the LAD), so infarction of the basal septum would imply involvement of the proximal LAD or LMCA.Unless there is a concomitant anterior STEMI (high occlusion resulting in STEMI of anterior and basal walls), STE in aVR is not a STEMI in lead aVR; rather the STE in aVR is reciprocal to a leftward and inferior ST depression axis caused by diffuse subendocardialischemia

Case 3

• 20/male with syncope

Brugada

• Type 1 (Coved ST segment elevation >2mm in >1 of V1-V3 followed by a negative T wave) is the only ECG abnormality that is potentially diagnostic. This has been referred to as Brugada sign.

Case 4

• 70/male with SOB. Hx – HPT/IHD/CKD

HyperK, hypoCa

• There are peaked T-waves

• There is a long ST segment, resulting in a long QTc (490 ms).

Case 5

AIVR concordant

• AIVR

– No p wave

– Rate <100/min

• Concordant ST elevation in lead V4

• STEMI

Case 6

• 60/male with chest pain

LBBB

• The blue arrow shows the direction of the terminal deflection of the QRS

• The red arrows shows the direction of the ST segment and the T wave.

The rule of appropriate T wave discordance

• T wave should be deflected opposite the terminal deflection of the QRS complex

• The terminal deflection is the last deflection, or wave, of a QRS complex.

Case 7

• 60/ female with chest pain

RBBB + LAFB + STEMI

• P wave

• LAFB

– LAD

– R in I & aVL

• STEMI

– Concordance STE V3-V4, possible I & aVL

Case 8

• 40/male with acute SOB

Mobitz 1 (wenkenbach)

• Prolong PR & drop beat

• STEMI

– Inferior

• Minimal horizontal STE

• Reciprocal @ aVL

– Possible posterior

Case 9

• 60/female with chest pain

Mobitz 2

• PR maintained

• Drop 2nd & 6th beat

Case 10

• 40/ male with intermittent chest pain 3/7

Wellen’s

• 2 type– Biphasic T

– Deep symmetrical T

• indicative of reperfusion of the infarct-related vessel– Spontaneously open

– Good collateral

• LAD occlusion

• Danger– Pseudonormalization (reocclusion)

Case 11

• 40/ male sudden onset chest pain

De Winter’s T

• de Winter T- waves

• 1-3 mm of ST-depression upsloping at the J-point in the precordial leads, leading into tall symmetric T-waves

• High risk of acute anterior MI

• Suggestive of an acute proximal LAD occlusion (contrast to sub-acute occlusion of Wellenssyndrome)

Case 12

• 40/M/Male

• C/o Palpitation

VT vs SVT with aberancy

RBBB like morphology

Qs wave in v6 -> VT

LBBB like morphology

Tq