cardiology/ekg board review - philadelphia college … • review general method for ekg...
TRANSCRIPT
ObjecCves
• ReviewgeneralmethodforEKGinterpretaCon• Reviewspecificpointsof“datagathering”and“diagnoses”onEKG
• ReviewtreatmentconsideraCons• Reviewclinicalcases/EKG’s• BoardexamconsideraCons
EKG–12Leads
• AnteriorLeads-V1,V2,V3,V4• InferiorLeads–II,III,aVF• LeVLateralLeads–I,aVL,V5,V6• RightLeads–aVR,V1
11StepMethodforReadingEKG’s
• “DataGathering”–steps1-4– 1.StandardizaCon–makesurepaperandpaperspeedisstandardized
– 2.HeartRate– 3.Intervals–PR,QT,QRSwidth– 4.Axis–normalvs.deviaCon
11StepMethodforReadingEKG’s
• “Diagnoses”– 5.Rhythm– 6.Atrioventricular(AV)BlockDisturbances– 7.BundleBranchBlockorHemiblock of– 8.PreexcitaCon ConducCon– 9.EnlargementandHypertrophy– 10.CoronaryArteryDisease– 11.UgerConfusion
• TheOnlyEKGBookYou’llEverNeedMalcolmS.Thaler,MD
QTc
• QTc=QTintervalcorrectedforheartrate– UsesBazeg’sFormulaorFridericia’sFormula
• LongQTsyndrome–inheritedoracquired(>75meds);torsadesdeponites/VF;syncope,seizures,suddendeath
Rhythm
• 4QuesCons– 1.ArenormalPwavespresent?– 2.AreQRScomplexesnarroworwide(≤or≥0.12)?– 3.WhatisrelaConshipbetweenPwavesandQRS
complexes?– 4.Isrhythmregularorirregular?
• Sinusrhythm=normalPwaves,narrowQRScomplexes,1Pwavetoevery1QRScomplex,andregularrhythm
TypesofArrhythmias
• Arrhythmiasofsinusorigin• Ectopicrhythms• ConducConBlocks• PreexcitaConsyndromes
AVBlock• DiagnosedbyexaminingrelaConshipofPwavestoQRS
complexes• FirstDegree–PRinterval>0.2seconds;allbeats
conductedthroughtotheventricles• SecondDegree–onlysomebeatsareconductedthrough
totheventricles– MobitzTypeI(Wenckebach)–progressiveprolongaConofPRintervalunClaQRSisdropped
– MobitzTypeII–All-or-nothingconducConinwhichQRScomplexesaredroppedwithoutPRintervalprolongaCon
• ThirdDegree–Nobeatsareconductedthroughtotheventricles;completeheartblockwithAVdissociaCon;atriaandventriclesaredrivenbyindividualpacemakers
BundleBranchBlocks
• RBBBcriteria:– 1.QRScomplex>0.12seconds– 2.RSR’inleadsV1andV2(rabbitears)withSTsegmentdepression
andTwaveinversion– 3.ReciprocalchangesinleadsV5,V6,I,andaVL
• LBBBcriteria:– 1.QRScomplex>0.12seconds– 2.BroadornotchedRwavewithprolongedupstrokeinleadsV5,V6,I,
andaVLwithSTsegmentdepressionandTwaveinversion.– 3.ReciprocalchangesinleadsV1andV2.– 4.LeVaxisdeviaConmaybepresent.
Hemiblocks
• DiagnosedbylookingatrightorleVaxisdeviaCon
• LeVAnteriorHemiblock– 1.NormalQRSduraConandnoSTsegmentorTwavechanges– 2.LeVaxisdeviaCongreaterthan-30°– 3.NoothercauseofleVaxisdeviaConispresent
• LeVPosteriorHemiblock– 1.NormalQRSduraConandnoSTsegmentorTwavechanges– 2.RightaxisdeviaCon– 3.NoothercauseofrightaxisdeviaConispresent
BifascicularBlock
• RBBBwithLAH– RBBB–QRS>0.12secandRSR’inV1andV2withLAH–leVaxisdeviaCon
• RBBBwithLPH– RBBB–RS>0.12secandRSR’inV1andV2withLPH–rightaxisdeviaCon
PreexcitaCon• Wolff-Parkinson-White(WPW)Syndrome
– 1.PRinterval<0.12sec– 2.WideQRScomplexes– 3.Deltawavesseeninsomeleads
• Lown-Ganong-Levine(LGL)Syndrome–– 1.PRinterval<0.12sec– 2.NormalQRSwidth– 3.Nodeltawave
• CommonArrhythmias– ParoxysmalSupraventricularTachycardia(PSVT)–narrowQRS’saremorecommonthanwideQRS’s
– AtrialFibrillaCon–canberapidandleadtoventricularfibrillaCon
SupraventricularArrhythmias• PSVT-regular;Pwavesretrogradeifvisible;rate150-250bpm;
caroCdmassage:slowsorterminates• Fluger–regular;saw-toothedpagern;2:1,3:1,4:1,etc.block;
atrialrate250-350bpm;ventricularrate½,⅓,¼,etc.ofatrialrate;caroCdmassage:increasesblock
• FibrillaCon–irregular;undulaCngbaseline;atrialrate350to500bpm;variableventricularrate;caroCdmassage:mayslowventricularrate
• MulCfocalatrialtachycardia(MAT)–irregular;atleast3differentPwavemorphologies;rate–usually100to200bpm;someCmes<100bpm;caroCdmassage:noeffect
• PAT–regular;100to200bpm;characterisCcwarm-upperiodintheautomaCcform;caroCdmassage:noeffect,ormildslowing
RulesofAberrancyVentricularTachycardia Paroxysmal
supraventricularTachycardia
ClinicalCluesClinicalHistory Diseasedheart Usuallynormalheart
CaroCdMassage Noresponse Mayterminate
CannonAWaves Maybepresent Notseen
EKGCluesAVDissociaCon Maybeseen Notseen
Regularity Slightlyirregular Veryregular
FusionBeats Maybeseen Notseen
IniCalQRSdeflecCon MaydifferfromnormalQRScomplex
SameasnormalQRScomplex
AtrialEnlargement• LookatPwavesinleadsIIandV1• Rightatrialenlargement(Ppulmonale)– 1.IncreasedamplitudeinfirstporConofPwave– 2.NochangeinduraConofPwave– 3.PossiblerightaxisdeviaConofPwave
• LeVatrialenlargement(pmitrale)– 1.Occasionally,increasedamplitudeofterminalpartofPwave
– 2.Moreconsistently,increasedPwaveduraCon– 3.NosignificantaxisdeviaCon
VentricularHypertrophy• LookattheQRScomplexesinallleads• Rightventricularhypertrophy(RVH)
– 1.RAD>100°– 2.RaCoofRwaveamplitudetoSwaveamplitude>1inV1and<1inV6
• LeVventricularhypertrophy(LVH)
PrecordialCriteria LimbLeadCriteriaRwaveinV5orV6+SwaveinV1orV2>35mm
RwaveinaVL>13mm
RwaveinV5>26mm RwaveinaVF>21mm
RwaveinV6>18mm RwaveinI>14mm
RwaveinV6>RwaveinV5
RwaveinI+SwaveinIII>25mm
MyocardialInfarcCon
• Dx–Hx,PE,serialcardiacenzymes,serialEKG’s
• 3EKGstagesofacuteMI– 1.Twavepeaksandtheninverts– 2.STsegmentelevates– 3.Qwavesappear
QWaves
• CriteriaforsignificantQwaves– Qwave>0.04secondsinduraCon– Qwavedepth>⅓heightofRwaveinsameQRScomplex
• CriteriaforNon-QWaveMI– Twaveinversion– STsegmentdepressionpersisCng>48hoursinappropriateclinicalse{ng
LocalizingMIonEKG• InferiorinfarcCon–leadsII,III,aVF
– OVencausedbyocclusionofrightcoronaryarteryoritsdescendingbranch
– ReciprocalchangesinanteriorandleVlateralleads• LateralinfarcCon–leadsI,aVL,V5,V6
– OVencausedbyocclusionofleVcircumflexartery– Reciprocalchangesininferiorleads
• AnteriorinfarcCon–anyoftheprecordialleads(V1-V6)– OVencausedbyocclusionofleVanteriordescendingartery– Reciprocalchangesininferiorleads
• PosteriorinfarcCon–reciprocalchangesinleadV1(STsegmentdepression,tallRwave)– OVencausedbyocclusionofrightcoronaryartery
STsegment• ElevaCon– SeenwithevolvinginfarcCon,Prinzmetal’sangina– Othercauses–JpointelevaCon,apicalballooningsyndrome,acutepericardiCs,acutemyocardiCs,hyperkalemia,pulmonaryembolism,Brugadasyndrome,hypothermia
• Depression– SeenwithtypicalexerConalangina,non-QwaveMI– Indicatorof+stresstest
ElectrolyteAbnormaliCesonEKG
• Hyperkalemia–peakedTwaves,prolongedPR,flagenedPwaves,widenedQRS,mergingQRSwithTwavesintosinewave,VF
• Hypokalemia–STdepression,flagenedTwaves,Uwaves
• Hypocalcemia–prolongedQTinterval• Hypercalcemia–shortenedQTinterval
Drugs• Digitalis– TherapeuCclevels–STsegmentandTwavechangesinleadswithtallRwaves
– Toxiclevels–tachyarrhythmiasandconducConblocks;PATwithblockismostcharacterisCc.
• MulCpledrugsassociatedwithprolongedQTinterval,Uwaves– Sotalol,quinidine,procainamide,disopyramide,amiodarone,dofeClide,dronedarone,TCA’s,erythromycin,quinolones,phenothiazines,variousanCfungals,someanChistamines,citalopram(onlyprolongedQTinterval–dose-dependent)
EKG∆’sinotherCardiacCondiCons• PericardiCs–DiffuseSTsegmentelevaConsandTwaveinversions;largeeffusionmaycauselowvoltageandelectricalalternans(alteringQRSamplitudeoraxisandwanderingbaseline)
• MyocardiCs–conducConblocks• HypertrophicCardiomyopathy–ventricularhypertrophy,leVaxisdeviaCon,septalQwaves
EKG∆’sinPulmonaryDisorders
• COPD–lowvoltage,rightaxisdeviaCon,andpoorRwaveprogression.
• Chroniccorpulmonale–PpulmonalewithrightventricularhypertrophyandrepolarizaConabnormaliCes
• Acutepulmonaryembolism–rightventricularhypertrophywithstrain,RBBB,andS1Q3T3(withTwaveinversion).SinustachycardiaandatrialfibrillaConarecommon.
EKG∆’sinOtherCondiCons• Hypothermia–Osbornwaves,prolongedintervals,sinusbradycardia,slowatrialfibrillaCon,bewareofmuscletremorarCfact
• CNSDisease–diffuseTwaveinversionwithTwaveswideanddeep,Uwaves
• Athlete’sHeart–sinusbradycardia,nonspecificSTsegmentandTwavechanges,RVH,LVH,incompleteRBBB,firstdegreeorWenckebachAVblock,possiblesupraventriculararrhythmia
UgerConfusion
• Verifyleadplacement• RepeatEKG• RepeatstandardizedprocessofEKGanalysis-starCngoverfromthebeginningwithbasics–rate,intervals,axis,rhythm,etc.andproceedthroughenCrestepwiseanalysis
• ConsiderCardiologyconsultaCon
ArrhythmiaIndicaConstoConsultCardiology
• DiagnosCcormanagementuncertainty• MedicaConsnotcontrollingsymptoms• PaCentisinhigh-riskoccupaConorparCcipatesinhigh-riskacCviCes(pilot,scubadriving)
• PaCentsprefersintervenConoverlong-termmeds• PreexcitaCon• Underlyingstructuralheartdisease• Associatedsyncopeorothersignificantsymptoms• WideQRS
CareConsideraConsPriortoCardiologyConsult
• ThoroughHxandPE• Basiclabs• EKGandrepeatEKG• Holtermonitor• Echocardiogram• Acuityofcarerequired–considerrisks,hemodynamicstability
PacemakerConsideraCons
• Third-degree(complete)AVblock• SymptomaCclesserdegreeAVblockorbradycardia
• SuddenonsetofvariouscombinaConsofAVblockandBBBduringacuteMI
• Recurrenttachycardiasthatcanbeoverdrivenandterminatedbypacemakers
OsteopathicConsideraCons
• Treatments–– LymphaCcs–thoracicinlet,abdominaldiaphragm,ribraising,lymphaCcpumps
– SympatheCcs(T1-T6)–cervicalganglion,ribraising,T1-T6,Chapman’sreflexes,T10-L2foradrenal/kidney
– ParasympatheCcs–OA/AA/cranial–vagusnerve
Case1• 53yearoldcaucasianfemalewith4dayhxofseverecentralchestpainonexerCon,previouslyalleviatedwithrest;nowworsenedoverlast24hoursandsustainedatrest
• PMHx–DM2,HTN,hyperlipidemia• Appearsunwell,inpain,sweaty,andgrey
Case1• PCIstenCngofLAD
• Post-procedure=resolvingSTelevaCon;lossofominoustombstoneeffect;Qwavesdeveloping
Case2
• 45yomalepresentswithacuteSOBs/plongvacaConinParis
• PMHx-asthma,Crohn’sdisease,anxiety,GERD,tobaccoabuse
• VS37,148/92,130,26• PaCentappearsuncomfortablebutotherwiseunremarkableexam
Case3
• 72yomalepresentstotheofficeforevaluaConpriortocataractsurgery
• Nocomplaints• PMHx–B/Lcataracts,OA,HTN,hyperlipidemia,andchroniclowbackpain
• VS37.2,152/86,74,14
Case4
• 27yofemalepresentstotheEDwithc/ochestdiscomfortandpalpitaConsaVerstudyingallnightforgraduateschoolexams
• Appearsnervousand“uneasy”withrapidpulse
• PMHx–unremarkable;nomeds,admitstooccasionalalcohol,non-smoker,deniesillicitdruguse,usedcoffeetostayawaketostudy
Case5
• 46yomalepresentstoEDwithc/osevereHApersisCngover5hoursdespiteacetaminophenandNSAIDagemptsasaborCvetherapy
• PMHx–occasionalleVshoulderpain,non-smoker
• ConstrucConworker• VSS;unremarkableexam
Case6
• 56yofemalepresentstofamilyphysicianwithc/olight-headednessandoccasionalflugerinherchest
• PMHx–anxiety,depression,obesity,smoker• Worksasretailstoremanager• VSS;coursebreathsounds,otherwiseunremarkableexam
Case6
• SeconddegreeAVblock–MobitzTypeI–Wenckebach(specifically3:2AVWenckebachphenomenonwhereevery3rdPwaveisblocked)
Case7
• 28yomalepresentsforcommercialdriver’slicense(CDL)evaluaCon
• Nocomplaints• VSS;asymptomaCc;examwithoutsignificantfindings
Case7
• TypicalpreexcitaCon(WPW)pagern• ShortPRintervalanddeltawavesinmanyleads
• TxiscloseobservaConunlesspaCenthashadSVToratrialfibrillaConwhichindicatestxwithablaConofaccessorypathway
Case8
• 32yomalepresentstoEDwithc/ofeelingsickforthelast6days
• Symptomsincludefevers,cough,anddifficultycatchinghisbreath
• PMHx–hyperlipidemia,obesity,metabolicsyndrome
• VS38.1,105,128/84,22
Case9
• 67yomalepresentstohiscardiologistforout-paCent6weekpost-hospitalvisit
• PrevioushospitalizaConfornon-cardiacchestpain
• Post-hospitalcardiacmeds–ACEinhibitor,betablocker,aspirin,nitrate
• Nocurrentcomplaints
Case9
• AtrialfibrillaCon–irregularlyirregularwithoutPwaves
• RBBB–wideQRSwithrsR’pagerninV1,broadSwavesinleadsIandaVL
• Inferiorinfarct–non-acute(>1week)pathologicQwavesininferiorleads(II,III,andaVF)
Case10
• 79yomalebroughttoEDviaEMSwithchestpain,SOB,andnear-syncope
• PMHx–unobtainablesecondarytopaCentdistress
• VS–36.9,140’s,82/40,28
Case10
• Monomorphicsustainedventriculartachycardia(VT)–couldrapidlydeteriorateintoVF,torsadesdepointes,asystole,orsuddendeath
Case11
• 82yofemaleadmigedtoacutecarehospitalsecondarytochestpain
• PMHx–HTN,DM2,CHF,obesity,depression• CardiologyplanningcardiaccatheterizaConsecondarytonewfindingduringiniCalconsultaCon
Case12
• 59yomalepresentstoEDdiaphoreCcandindistress
• PMHx–HTN,ESRD,DM2,LeVBKA• VS–37.5,108,96/58,24
Case12
• Hyperkalemia–tallpeakedTwavespresentthroughout;otherprogressiveEKGchangesmayfollowwithincreasingpotassiumlevels–prolongedPRinterval,flagenedPwaves,wideningQRS,sinewaves
• Sinustachycardiaalsopresent
BonusCase
• 18yomaleundergoingmilitaryphysicalexamandevaluaConpriortobootcamp
• Nocomplaints• PMHx–denies• VSS;examunremarkable
BoardExamPoints
• EKG’slikelytohave1mainfinding• ClinicalcaselikelyincludedwitheachEKG• QuesConlikelytofocusonclinicalcaseaswellasEKG
• Straightforwardwithouttricksorobscurefindings(notlikelytosee“zebras”)
• Focusoncommonarrhythmias,commoncardiacdiagnoses,commonnon-cardiacEKGabnormaliCes,oremergent“can’tmiss”diagnoses
Resources• SourcesandSuggestedReferences– TheOnlyEKGBookYou’llEverNeed-MalcolmS.Thaler– RapidInterpretaConofEKG’s–DaleDubin,M.D.– “…ExceptforOMT!”–DalePrag-Harrington– AmericanFamilyPhysician–November1,2015– UptoDate– blogatwordpress.com– cme.umn.edu– ekgcasestudies.com– healio.com– lifeinthefastlane.com– learntheheart.com