complex cardiac presentations & ecg interpretation · 2019-07-04 · a 55 year old man with 4...

Complex Cardiac Presentations

& ECG Interpretation

Simon Kennon Barnet & Royal Free Hospitals

Barts Heart Centre

Complex Cardiac Presentations

•  Chest Pain •  Breathlessness •  Palpitations •  Dizzy spell, collapses

2

Chest Pain ‒ male 45 smoker

1.  Lower central burning CP after eating, 6 weeks.

2.  Dull upper chest pain on walking to work, 3 months.

3.  Nocturnal chest tightness and SOB, 1 year.

4.  Prolonged episodes of left sided chest pain, 18 months.

5.  Central chest ache, 3 hours. 3

Chest Pain ‒ female 25 nonsmoker

1.  Lower central burning CP after eating, 6 weeks.

2.  Dull upper chest pain on walking to work, 3 months.

3.  Nocturnal chest tightness and SOB, 1 year.

4.  Prolonged episodes of left sided chest pain, 18 months.

5.  Central chest ache, 3 hours. 4

Breathlessness

1.  F70, NYHA 4, walked to GP surgery, smoker.

2.  M50, NYHA 1-2, BMI 28, 18 months

3.  F60, NYHA 2-3, 3-4 months.

4.  F40, SOB at any time, when speaking, 9 months

5.  M85, NYHA 2-3, and on bending over, BMI 30, 12 months. 5

Palpitations

1.  M45, Momentary bumps and jumps, esp at night ‒ 3 months.

2.  F45, Sudden onset, 10-60 minutes rapid and forceful, fade away ‒ 3 months.

3.  M25, Sudden onset, 10-60 minutes rapid and forceful, sudden stop ‒ 3 months.

4.  F55, Variable duration and characteristics ‒ 3 months.

6

Dizzy spells.

1.  M80, Dizzy on standing, sometimes collapse, 1 year.

2.  M65, Unheralded syncope with trauma.

3.  F25, Dizzy and nausea with syncope, when standing, 10 years.

4.  F25, Palpitations and dizziness, 10-60 minutes, 1 year

7

•  ecgpedia.org •  ecglibrary.com

8

ECG Interpretation

Electrocardiogram p p

QRS QRS

Electrocardiogram

P waves ‒ atrial depolarisation.

PR interval ‒ crossing AV node.

QRS ‒ ventricular depolarisation.

Electrocardiogram

Longer = slower - suggests ‘disease’ PR interval ‒ 1st HB QRS duration - BBB

ECG Rate ‒ beats per minute

Rhythm ‒ regular / irregular

P waves ‒ presence, PR interval, association with QRS

Rhythm - diagnosis

QRS duration

Axis

Other abnormalities ‒ Q waves, T wave inversion

Other abnormalities - ST segment elevation/depression

Heart Rate Heart rate in beats per minute = 300 / n (bpm) n = number of large squares between QRS complexes.

Tachycardia: >100bpm Bradycardia: <50bpm

13

Heart Rate

14

Heart Rate

15

Heart Rate

16

Heart Rate

17

Rhythm

Regular Irregular

18

P Waves

Sinus rhythm: - P wave before every QRS. - Unchanging PR interval. - PR interval 120-200ms (3-5 small squares).

19

P Waves

20

P Waves

21

P Waves

22

P Waves

23

P Waves

24

P Waves

25

P Waves

26

P Waves

27

09/03/2013 18:53Complete Heart Block

Page 1 of 1http://www.ecglibrary.com/chb4.html

A 70 year old man with exercise intolerance.

Complete Heart BlockP waves are not conducted to the ventricles because of block at the AV node. The P waves are indicated below andshow no relation to the QRS complexes. They 'probe' every part of the ventricular cycle but are never conducted.The ventricles are depolarised by a ventricular escape rhythm.

Go back to ECG homepage

P Waves

28

QRS duration

QRS duration: <120ms or <3 small squares

29

QRS duration

30

QRS duration

31

09/03/2013 18:53Left ventricular and left atrial hypertrophy

Page 1 of 2http://www.ecglibrary.com/lvhlah.html

An 83 year old man with aortic stenosis.

Left ventricular hypertrophy (LVH)There are many different criteria for LVH.

Sokolow + Lyon (Am Heart J, 1949;37:161)S V1+ R V5 or V6 > 35 mm

Cornell criteria (Circulation, 1987;3: 565-72)SV3 + R avl > 28 mm in menSV3 + R avl > 20 mm in women

Framingham criteria (Circulation,1990; 81:815-820)R avl > 11mm, R V4-6 > 25mmS V1-3 > 25 mm, S V1 or V2 +R V5 or V6 > 35 mm, R I + S III > 25 mm

Romhilt + Estes (Am Heart J, 1986:75:752-58)Point score system

Left atrial abnormality (dilatation or hypertrophy)M shaped P wave in lead IIprominent terminal negative component to P wave in lead V1 (shown here)

See also - mitral stenosis.

QRS duration

32

09/03/2013 18:54'Trifascicular' block

Page 1 of 1http://www.ecglibrary.com/trifas.html

A 90 year old lady with syncope.

'Trifasicular' blockComplete Right Bundle Branch BlockLeft Anterior HemiblockLong PR interval

The combination of RBBB, LAFB and long PR interval has been called 'trifasicular' block and implies thatconduction is delayed in the third fascicle (in this case the left posterior fascicle) and a permanent pacemaker may beneeded. However there are other causes of a long PR interval such as delayed conduction in the AV node or atrium so'trifascicular block' is not a true ECG diagnosis.


QRS duration

33

Bundle Branch Block

WILLIAM MORROW V1 and V6

LBBB ‒ WILLIAM RBBB ‒ MORROW

34







QRS Axis

Normal: V1 & V2 more positive than negative Left axis deviation: V2 & V3 more negative than positive. Right axis deviation: V1&V2 more negative than positive.

35

QRS axis

36

QRS axis

37











QRS axis

38







QRS axis

39

QRS axis

40

ECG report

This ECG is unremarkable with

sinus rhythm at a rate of 60

beats per minute with a normal

axis and QRS duration.

ECG report Multiple ‘diagnoses’:

SR and otherwise unremarkable

Atrial fibrillation and otherwise unremarkable.

SR with LBBB.

Atrial fibrillation with RBBB and left axis deviation.

SR with 1st degree heart block, LVH and an old inferior MI.

ECG report

SR with a normal axis and QRSD with one PVE

ECG report

SR with ventricular bigeminy, a normal axis & QRSD

Ventricular Trigeminy

ECG Report

SR with a normal axis & QRSD, anterior Q waves with

TWI leads V1-5

ECG report

Ventricular Tachycardia

Torsade de Pointes

Atrial Fibrillation & LAD

Atrial Flutter 4:1 block

Wolf Parkinson White & LAD

SupraVentricular Tachycardia (SVT)

Left Ventricular Hypertrophy 09/03/2013 18:53Left ventricular and left atrial hypertrophy










09/03/2013 18:52Acute Inferior Myocardial Infarction

Page 1 of 1http://www.ecglibrary.com/infmi.html

A 55 year old man with 4 hours of "crushing" chest pain.

Acute inferior myocardial infarctionST elevation in the inferior leads II, III and aVFreciprocal ST depression in the anterior leads

See also acute anterior MI.

Right Bundle Branch Block and sinus bradycardia are also present.


Inferior Myocardial Infarction 09/03/2013 18:52Acute Inferior Myocardial Infarction

Page 1 of 1http://www.ecglibrary.com/infmi.html

A 55 year old man with 4 hours of "crushing" chest pain.

Acute inferior myocardial infarctionST elevation in the inferior leads II, III and aVFreciprocal ST depression in the anterior leads

See also acute anterior MI.

Right Bundle Branch Block and sinus bradycardia are also present.


Bifascicular Block ‒ RBBB & LAD 09/03/2013 18:54'Trifascicular' block






09/03/2013 18:53Complete Heart Block





Complete Heart Block & LBBB 09/03/2013 18:53Complete Heart Block





Complete Heart Block

Normal ECG

Probable Old Inferior MI

Normal ECG ‒ non-pathological Q waves

Old Anterior MI

LVH with a ‘strain pattern’

Atrial Fibrillation

Pacemaker in situ

Left Bundle Branch Block (LBBB)

Trifascicular Block ‒ RBBB & LAD & 1st HB

2nd Degree Heart Block

Complete (3rd degree) Heart Block

1st degree Heart Block & LAD & LVH

Left Axis Deviation

?Pericarditis

24 hour tape

Difficult!

Limited value - AF rate control, daily palpitations

Variable quality

Specific indication

Reports usually good

101

Name: SNELLING, Brian Date of birth: 22/06/1948 Date: 03/04/2017

ID number: 198140 Gender: M Channel: 3+1 Page: 1/11

Version 2.2.1.8 | 2.2.1.8 CardioDay® for Windows®, getemed AG, Teltow

_______________________________________________________________________

Referred by: 20173 BMI The Kings Oak Hospital Dr KennonIndication: Medication: Comments: Start of recording: 03/04/2017 09:21(1), Duration: 47:59 h , Recorder SN/ID: 340 07 4660 211

S U M M A R Y

Day 1 and 2 of 3 day Holter recording.

QRS Complexes: 158856 Artifacts: 43

VENTRICULAR EVENTS SUPRAVENTRICULAR EVENTSVentricular escapes: 0 SVE (Prematurity < 80 %): 1541 PVC (Prematurity < 90 %): 206 SVT Tachycardia (>120 1/min): 8Bigeminy: 9 -longest: 6.3 s at 18:16(2)Couplets: 1 -fastest: 144 bpm at 14:36(1)Triplets: 0VE Runs: 0 ARRHYTHMIA-fastest: Arrhythmias (Delay > 140 %): 0VE Tachycardias (>4): 0 -longest: -longest: Bradycardias (< 50 1/min): 964-fastest: -slowest: 43/min at 23:49(2) Pauses (>2000 ms): 0VE/QRS Ratio: 0.15 % -longest:

HEART RATE Minimum: 43/min at 09:15(1)Mean: 56/minMaximum: 96/min at 14:35(1)___________________________________________________________________________

D I A G N O S I S

07/04/2017

Sinus rhythm seen throughout recording. Infrequent ventricular activity included a couplet, bigeminy and isolated extrasystoles. Infrequent supraventricular activity included non-sustained atrial tachycardias, non-sustained atrial runs, atrial triplets and atrial couplets. Nocturnal bradycardia was also seen.

TECHNICAL: Medium quality recording.

ANALYST: Mary Cox___________________

102

Name: SNELLING, Brian Date of birth: 22/06/1948 Date: 03/04/2017



114:35:00

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N62197

N62596

N61797

N62596

N62197

N63395

N62596

N504119

N75080

N62995

N543111

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2

3

Event: 1 03/04/2017 14:35:34 (1) Maximum Heart Rate 25 mm/s10 mm/mV98/min

109:15:16

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N140243

N136344

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Event: 2 04/04/2017 09:15:50 (1) Minimum Heart Rate 25 mm/s10 mm/mV43/min

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N N120750

N120750

N116452

N119950

N116851

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Event: 3 04/04/2017 11:00:01 (2) Diary Time 25 mm/s10 mm/mV50/min

103

Name: GRUNDY, RUSSELL Date of birth: 11/06/1971 Date: 04/04/2017



Heart rate140

120

100

80

60

40

20

0

1/min

09:00 11:00 13:00 15:00 17:00 19:00 21:00 23:00 01:00 03:00 05:00 07:00 [h]

Event histograms

09:00 11:00 13:00 15:00 17:00 19:00 21:00 23:00 01:00 03:00 05:00 07:00 [h]

2

1

4

15

1

R on T0

VE tachyc.0

VE run0

Triplet0

Couplet0

Bigeminy0

PVC86

R-R pause3

Bradycardia517

N-N delay0

SVE tachyc.0

SVE303

Vent. esc.0

Noise1

Patient1

1

Echocardiogram

MRI gold standard for structure and function

Diastolic dysfunction and mild valvular

regurgitation rarely important.

Impairment of LV function / LV dilation important

Variable quality images and reports

Clinical correlation important

Specific indication

2 year outcome TAVI (n=1011)

AVR (n=1021)

p

Mortality or CVA %

19.3 21.1 0.33

Mortality % 16.7 18.0 0.45

CVA% 9.5 8.9 0.67 PVL % 8.0 0.6 <0.001 AF % 11.3 27.3 <0.001 PPM % 11.8 10.3 0.29

Leon et al NEJM 2016 Randomised trial. TAVI vs AVR 2032 patients Intermediate risk as per ‘the Heart team’. - TF 76.3% Average STS = 5.8% Average age 82

Intermediate Risk Patients The PARTNER 2a Trial

n engl j med nejm.org 6

T h e n e w e ngl a nd j o u r na l o f m e dic i n e

with TAVR plus PCI (19.3% and 20.5%, respective-ly; P = 0.84) and surgery alone with surgery plus CABG (20.9% and 21.5%, respectively; P = 0.90).

Multivariate predictors of death from any cause in the overall trial as well as in each of the trial groups are presented in Table S7 in the Supplementary Appendix. Treatment assignment to TAVR or surgery was not a significant predic-tor of mortality. The time-dependent effects of disabling stroke, life-threatening bleeding, acute

kidney injury, and major vascular complication were all significantly associated with a higher risk of death over the period of 2 years in both the TAVR group and the surgery group (P<0.001 for all comparisons).

Other Clinical End PointsAt 30 days, major vascular complications were more frequent in the TAVR group than in the surgery group (7.9% vs. 5.0%, P = 0.008) (Ta-

Figure 1. Time-to-Event Curves for the Primary Composite End Point.

The insets show the same data on an enlarged y axis. TAVR denotes transcatheter aortic-valve replacement.

Dea

th fr

om A

ny C

ause

or D

isab

ling

Stro

ke (%

)100

80

60

20

40

00 3 6 15 18 21 24

Months since Procedure

A Intention-to-Treat Population

No. at RiskTAVRSurgery

10111021

918838

901812

825747

12

842770

9

870783

811735

801717

774695

C Transfemoral-Access Cohort, Intention-to-Treat Analysis

Dea

th fr

om A

ny C

ause

or D

isab

ling

Stro

ke (%

)

100

80

60

20

40

00 3 6 15 18 21 24



775775

718643

709628

652577

12

663595

9

685604

644569

634557

612538

D Transfemoral-Access Cohort, As-Treated Analysis

Dea

th fr

om A

ny C

ause

or D

isab

ling

Stro

ke (%

)100

80

60

20

40

00 3 6 15 18 21 24



762722

717636

708624

652573

12

663591

9

685600

644565

634555

612537

B As-Treated Population

Dea

th fr

om A

ny C

ause

or D

isab

ling

Stro

ke (%

)

100

80

60

20

40

0

90

70

30

50

10

90

70

30

50

10

90

70

30

50

10

90

70

30

50

10

0 3 6 15 18 21 24



994944

917826

900807

825743

12

842766

9

20

40

0

30

50

10

0 3 6 15 18 21 24129

20

40

0

30

50

10

0 3 6 15 18 21 24129

20

40

0

30

50

10

0 3 6 15 18 21 24129

20

40

0

30

50

10

0 3 6 15 18 21 24129

870779

811731

801715

774694

Hazard ratio, 0.89 (95% CI, 0.73–1.09)P=0.25

TAVR

Surgery14.5

16.419.3

21.1

Hazard ratio, 0.79 (95% CI, 0.62–1.00)P=0.05

12.3

15.916.8

20.4

TAVR

Surgery

Hazard ratio, 0.87 (95% CI, 0.71–1.07)P=0.18

14.0

16.618.9

21.0

TAVR

Surgery

Hazard ratio, 0.78 (95% CI, 0.61–0.99)P=0.04

11.7

15.8

16.3

20.0

TAVR

Surgery

The New England Journal of Medicine Downloaded from nejm.org on April 2, 2016. For personal use only. No other uses without permission.

Copyright © 2016 Massachusetts Medical Society. All rights reserved.

Mack et al NEJM 2019 Randomised trial. TAVI vs AVR 1000 patients Low risk: STS<4 Excluded: Bicuspid AV ‘Frailty’ as per heart team Elevated anatomical risk for TAVI or AVR

Low Risk Patients The PARTNER 3 Trial

TAVI (n=496)

AVR (n=454)

p

Primary outcome (12mo)

8.5 15.1 <0.001

Death/CVA 30 days 1.0 3.3 <0.001

CVA 30 days 0.6 2.4 0.02

AF 5.0 39.5 <0.001

LoS 3.0 7.0 <0.001

PPM 6.5 4.0 0.09

111 TAVI: 1hour procedure; 48hour LoS

Transcatheter Aortic Valve Implantation (TAVI)

complex cardiac presentations & ecg interpretation · 2019-07-04 · a 55 year old man with 4...

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