Some Interesting EKGs

Justin Fox, MD

Fellow in Cardiovascular Disease

Northwestern Memorial Hospital

Thank You: EKG Maven, http://ecg.bidmc.harvard.edu/maven/mavenmain.asp

Asymptomatic 26yo ….

Normal EKG (with possible T wave abnormality in III)

Method of EKG Interpretation

• Rate (300, 150, 100, 75, 60, 50)• Rhythm (Is it NSR?)• Axis (Normal -30 to +90)• Intervals• Chamber enlargement/hypertrophy• q waves, ST segments, R wave

progression, T waves, etc• Pattern Recognition

Another asymptomatic 26yo…

Ectopic atrial rhythm – look at p wave axis before deciding on sinus rhythm.

A sinus P wave should be upright in inferior leads, and negative in aVR

47yo M w/ Chest Pain

http://library.med.utah.edu/kw/ecg/mml/ecg_12lead028.html

Anterior ST elevations, Tombstoning, reciprocal depressions inferiorly. Acute AWMI

Another 47yo M w/ Chest Pain

Pericarditis, diffuse ST elevation, PR elevation aVR

47yo M w/ chest pain (R sided V1-V6)

IWMI w/ posterior and RV involvement (STE in V4R), likely RCA infarct (STE in III greater than II suggests RCA more likely than LCx)

75yo M w/ Chest Pain

http://www.sbhemresidency.com/html/2004-05_ekg_quizzes.html

Diffuse ST depressions with ST elevation in aVR. This suggests global ischemia – i.e. 3v dz or L main disease

32yo asymptomatic man

Wolff-Parkinson-White Syndrome

What Could Happen to That Guy

AF w/ RVR/WPW @234, Treat w/ Procainamide, which slows conduction thru bypass tract. (This EKG is on the internal medicine boards)

Another interesting 32yo M

Brugada Syndrome – RBBB type pattern with ST elevations V1-2. Sodium channelopathy, associated with sudden death.

What Might Happen to This Guy

69yo F w/ Dyspnea and Clear CXR

Sinus Tachycardia w/ S1Q3T3 pattern suggestive of PE

What’s the rhythm?

Sinus rhythm w/ motion artifact due to Parkinson’s Disease. Note “flutter waves” only seen in leads that use R arm lead (and V1). Pt’s tremor is worse on right.

What’s the Rhythm?

Left leg tremor 2/2 CVVHD artifact (vascath in L femoral vein). “Flutter” went away when CVVH machine was paused. Also low voltage QRS.

74yo F…..

http://library.med.utah.edu/kw/ecg/mml/ecg_12lead016.html

RBBB with a L axis due to L anterior fascicular block (qR in I and aVL, rS in III). This is bifascicular block

How is this one different?

www.ecglibrary.com/ecgs/trifas2.gif

Same as prior but now w/ PR prolongation. This is “trifascicular block” – either left posterior fascicle is slow or AV node disease

What’s Wrong With This Patient’s Dual Chamber Pacemaker?

http://sprojects.mmi.mcgill.ca/heart/comments/exe000207r3.html

V-paced w/ RBBB pattern. PPM perforated septum, pacing now coming from LV cavity. (This is also seen with a normally functioning BiV pacer).

80yo M w/ longstanding AFib

AF w/ CHB and Junctional escape, Dig toxicity

What’s This?

Bidirectional VT, Dig toxicity

Huh?Ghany R and de Marchena E. N Engl J Med 2007;356:e6

2 hearts – heterotopic heart transplant with native heart left in position.

Some Extras….

And another asymptomatic 26yo…

Limb lead reversal (neg p and neg QRS in I), aVL looks like aVR should, also sinus arrhythmia

http://library.med.utah.edu/kw/ecg/ecg_outline/Lesson6/index.html

#1=AV Wenckebach (4:3, then 3:2); #2=SA Wenckeach (4:3); #3=Pacemaker Wenckebach

http://www.cardiosource.com/casestudies/casestudy.asp?TabID=4372&studyID=493

Rhythm Strips From 3 Different Patients

Patel A and Getsos J. N Engl J Med 1994;330:680

What’s The Rhythm?

Saadlla H. N Engl J Med 2004;351:e4

A better look at Osborn Waves

What’s the Lab Abnormality?

Hyperkalemia