the 12 lead ecg in pipreoperative cdi lcardiovascular risk ...€¦ · wayne ruppert bio: 2012...
TRANSCRIPT
![Page 1: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/1.jpg)
The 12 Lead ECG in
P iPreoperativeC di lCardiovascularRisk AssessmentRisk Assessment
WAYNE W RUPPERT, CVT, CCC, NREMT-P, , ,Interventional Electrophysiology TechnologistInterventional Cardiovascular Technologist
Cardiovascular Clinical CoordinatorCardiovascular Clinical CoordinatorBayfront Health Dade City Dade City, FL
Cardiovascular EducatorTwin Oaks Anesthesia ServicesWesley Chapel, FL
![Page 2: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/2.jpg)
![Page 3: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/3.jpg)
![Page 4: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/4.jpg)
![Page 5: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/5.jpg)
![Page 6: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/6.jpg)
![Page 7: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/7.jpg)
Published 2010 Published 2015
TriGen Publishing: Marketed and Distributed worldwide byThe Ingram Book Company
www.ECGtraining.org
![Page 8: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/8.jpg)
Wayne Ruppert bio:
2012 – Present: Bayfront Health Dade City2012 – Present: Bayfront Health Dade CityCardiovascular Clinical CoordinatorStroke CoordinatorPrincipal Investigator, “Simple Acute Coronary Syndrome
(SACS Risk Stratification Score – Scientific Validation Study and Comparison to Modified TIMI and HEART ACS Risk Stratification Scores, NIH #NCT
1994 – 2012: St Joseph’s Hospital Tampa FL1994 2012: St Joseph s Hospital, Tampa, FLInterventional Cardiovascular TechnologistCardiac Electrophysiology Technologist12 Lead ECG Instructor, Education Department
2010: Author, Editor, “12 Lead ECG Interpretation in Acute Coronary Syndrome with Case Studies from the Cardiac Catheterization Lab,” 310 page textbook marketed by Ingram Book Company. y g p y
-1982 – present, Paramedic (National Registry, Pennsylvania, Florida)-1982 - present, AHA ACLS Instructor1988 present AHA PALS Instructor-1988 – present, AHA PALS Instructor
![Page 9: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/9.jpg)
Course Reference Sources:
F 2014 ACC/AHA G id li P i ti C di l E l ti dFrom: 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice GuidelinesJ Am Coll Cardiol. 2014;64(22):e77-e137. doi:10.1016/j.jacc.2014.07.944
Stoeltingʹs Anesthesia and Co-Existing Disease, 5th Edition
EXPERT CONSULT - ONLINE AND PRINT By Roberta L. Hines, MD and Katherine E.Marschall, MD
![Page 10: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/10.jpg)
Course Syllabus:• Pre-operative Verbal History for Cardiovascular Disorders• The Normal ECG• Bundle Branch Blocks• Myocardial Infarction• Myocardial Ischemia
Old MI• Old MI• Brugada Syndrome• Long QT Syndrome (LQTS)• Wolff Parkinson White Syndrome (WPW)• Wolff-Parkinson-White Syndrome (WPW)• Arrhythmogenic Right Ventricular Dysplasia (ARVD)• Pericarditis / Myocarditis • HypertrophyHypertrophy
- Hypertrophic Cardiomyopathy (HCM) - Valvular Disorders- Cor Pulmonale
•Atrial Fibrillation /Flutter
![Page 11: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/11.jpg)
Preoperative CV Diagnostic Tests:
• 12 Lead ECG• EchocardiogramEchocardiogram• Stress Test• CT / MRI
C di C th t i ti• Cardiac Catheterization
![Page 12: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/12.jpg)
The need for PREOPERATIVE CAD Risk Factor Assessment . . . .
Does the NORMAL ECG rule out OBSTRUCTIVE Coronary Artery Disease ??
![Page 13: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/13.jpg)
“The WORST coronaryThe WORST coronary vasculature I have seen in nearly 20 years -- annearly 20 years an estimated 12,000 cases -- in the CATH LAB . . . And this patient’s 12 Lead ECG was essentially normal !!”
![Page 14: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/14.jpg)
ACS Risk Stratification: HEART ScoreHistory Highly suspicious ……………………...… 2
Moderately suspicious ………………… 1Slightly/not suspicious ………………… 0
ECG ST Depression ………………………….. 2Non-specific repol. Abnormality………… 1Normal ……………………………………. 0Normal ……………………………………. 0
Age 65 + ………………………………………. 245-65 ……………………………………...1< 45 0< 45 …………………………………..…… 0
Risk Factors 3 + Risk Factors –or-- known CAD ……. 21 or 2 Risk Factors ……………………… 1No known Risk Factors ………………… 0
Troponin 3X or more normal limit ………………….22 x normal limit 12 x normal limit ……………………………1Normal ……………………………………. 0
![Page 15: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/15.jpg)
From: 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: A Report of the
CLASS IIa1 A lid t d i k di ti t l b f l i di ti
American College of Cardiology/American Heart Association Task Force on Practice Guidelines
1. A validated risk-prediction tool can be useful in predictingthe risk of perioperative MACE in patients undergoingnoncardiac surgery (37,114,115). (Level of Evidence: B)
![Page 16: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/16.jpg)
Regarding ACS Risk Stratification tools:• Modified TIMI ACS Score has been “national
standard” for several years• “Modified TIMI Risk Score CANNOT be used to
identify low-risk chest pain in the ED” Emerg Med J 2014 Apr; 31 (14):281 5Emerg Med J 2014 Apr; 31 (14):281-5
• “Prospective Validation of HEART Score for Chest Pain patient in the ED ”Chest Pain patient in the ED, Int J Cardiol 2013 Oct 3;168(3):2153-8
• Study to validate Simple Acute Coronary Syndrome (SACS) Score + comparison to HEART and Modified TIMI: www.clinicaltrials.gov NIH St d ID # NCT02358148Study ID # NCT02358148
![Page 17: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/17.jpg)
The Simple Acute Coronary Syndrome
(SACS) Score
Developed in 2009 from noting correlations between patients’ SYMPTOMS, ECG RESULTS, RISK FACTOR PROFILE and CARDIAC MARKERS in approximately 12,000 patients.
A scientific study to VALIDATE this score, and to compare its accuracy and reliability to the Modified TIMI and HEART S f di i hHEART Scores for predicting the presence of OBSTRUCTIVE CORONARY ARTERY DISEASE is in progress at Bayfront Health Stprogress at Bayfront Health St Petersburg and Bayfront Health Dade City.
NIH St d ID # NCT02358148NIH Study ID # NCT02358148www.clinicaltrials.gov
![Page 18: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/18.jpg)
![Page 19: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/19.jpg)
HEART Score
+SACS Score
= ?
![Page 20: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/20.jpg)
![Page 21: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/21.jpg)
![Page 22: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/22.jpg)
![Page 23: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/23.jpg)
![Page 24: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/24.jpg)
![Page 25: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/25.jpg)
![Page 26: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/26.jpg)
![Page 27: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/27.jpg)
![Page 28: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/28.jpg)
![Page 29: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/29.jpg)
![Page 30: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/30.jpg)
THE 12 LEAD ECG HAS TWO MAJOR BLIND SPOTS . .
![Page 31: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/31.jpg)
THE 18 LEAD ECG COVERS THE ENTIRE HEART . .
![Page 32: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/32.jpg)
To do 18 Lead ECG with 12 Lead machine – after you obtain 12 Lead, reposition CHESTreposition CHEST LEADS to this configuration, then
i t !print !
![Page 33: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/33.jpg)
INDICATIONS for 18INDICATIONS for 18 Lead ECG include:Lead ECG include:
INFERIOR WALL MI- INFERIOR WALL MI- ST Depression in
LEADS V1 V4LEADS V1-V4
![Page 34: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/34.jpg)
QuickQuick ReviewReview OfOf Essential Waveforms
![Page 35: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/35.jpg)
![Page 36: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/36.jpg)
![Page 37: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/37.jpg)
![Page 38: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/38.jpg)
![Page 39: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/39.jpg)
![Page 40: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/40.jpg)
![Page 41: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/41.jpg)
What about biphasic QRS ?
![Page 42: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/42.jpg)
![Page 43: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/43.jpg)
![Page 44: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/44.jpg)
![Page 45: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/45.jpg)
![Page 46: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/46.jpg)
![Page 47: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/47.jpg)
![Page 48: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/48.jpg)
![Page 49: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/49.jpg)
![Page 50: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/50.jpg)
![Page 51: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/51.jpg)
• Add slide “ QRS amplitude too high –• “THINK: hypertrophyTHINK: hypertrophy.
![Page 52: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/52.jpg)
![Page 53: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/53.jpg)
![Page 54: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/54.jpg)
![Page 55: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/55.jpg)
THE MARKERS of ACUTE CORONARY SYNDROME . . . .
![Page 56: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/56.jpg)
![Page 57: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/57.jpg)
![Page 58: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/58.jpg)
![Page 59: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/59.jpg)
CHANGES ASSOCIATEDWITHCELLULARPERFUSION INVOLVINGINVOLVINGTHE:
‐ QRS ‐ J POINTST SEGMENT‐ ST SEGMENT
‐ T WAVE
![Page 60: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/60.jpg)
![Page 61: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/61.jpg)
![Page 62: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/62.jpg)
An inverted T wave in TWO OR MORE CONTIGUOUS LEADS = potentialCONTIGUOUS LEADS = potential problem ( ischemia )
![Page 63: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/63.jpg)
![Page 64: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/64.jpg)
HYPERACUTEHYPERACUTET WAVEST WAVES
![Page 65: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/65.jpg)
ECG CRITERIA for DIAGNOSIS of STEMI: (ST ELEVATION @ J POINT)(ST ELEVATION @ J POINT)
*LEADS V2 and V3: MALES ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ 2.0 mmFEMALES ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ 1.5 mmFEMALES 1.5 mm
ALL OTHER LEADS: 1.0 mm or more,
in TWO or more
CONTIGUOUS LEADS
* P. Rautaharju et al, “Standardization and Interpretation
of the ECG ” JACC 2009;(53)No 11:982 991of the ECG, JACC 2009;(53)No.11:982‐991
![Page 66: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/66.jpg)
Reciprocal S‐T Segment Depression may or may not be present during AMI.
The presence of S‐T Depression on an EKG which exhibits significant S‐T elevation is awhich exhibits significant S T elevation is a fairly reliable indicator that AMI is the diagnosisdiagnosis.
H h l k f R i l S THowever the lack of Reciprocal S‐T Depression DOES NOT rule out AMI.
![Page 67: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/67.jpg)
![Page 68: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/68.jpg)
![Page 69: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/69.jpg)
![Page 70: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/70.jpg)
![Page 71: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/71.jpg)
ANTERIOR WALL STEMILEFT ANTERIOR DESCENDING (LAD) ARTERY-LEFT ANTERIOR DESCENDING (LAD) ARTERY
ANTICIPATED COMPLICATIONS based on structures fed by the LAD:
C OG C S OC- LV PUMP FAILURE and CARDIOGENIC SHOCK (LAD feeds approx 45% of LV muscle mass)
PULMONARY EDEMA- PULMONARY EDEMA (resulting from depressed LV function)
- COMPLETE HEART BLOCK with IDIO-COMPLETE HEART BLOCK with IDIOVENTRICULAR ESCAPE Complexes (resulting from failure of Bundle of HIS and Bundle Branches)
![Page 72: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/72.jpg)
![Page 73: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/73.jpg)
![Page 74: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/74.jpg)
![Page 75: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/75.jpg)
When there is ALSO ST Elevation in Leads I & AVLA d/ ST DEPRESSION iAnd/or ST DEPRESSION in Inferior Leads II, III, AVF . . . .. . . .. .
![Page 76: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/76.jpg)
![Page 77: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/77.jpg)
+
=
![Page 78: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/78.jpg)
ST Elevation in Lead AVR with STEMI ? ?
![Page 79: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/79.jpg)
ST ELEVATION in Lead AVRST ELEVATION in Lead AVRWith STEMI . . . . . THINK “LEFT MAIN CORONARYTHINK “LEFT MAIN CORONARY ARTERY OCCLUSION !”
![Page 80: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/80.jpg)
When LEAD AVR shows ST Elevation:
STEMI: consider occlusion- STEMI: consider occlusion of the Left Main Coronaryof the Left Main Coronary Artery.
- NSTEMI and Unstable Angina consider LMCAAngina consider LMCA Occlusion – or TRIPLEOcclusion or TRIPLE VESSEL DISEASE
![Page 81: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/81.jpg)
![Page 82: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/82.jpg)
STEMI from Left Main Coronary Artery occlusion =GLOBAL WALL MI:GLOBAL WALL MI: - 75% Mortality Rate75% Mortality Rate- Cardiogenic Shock- Pulmonary Edema
Imminent Cardiac Arrest- Imminent Cardiac Arrest- Standard “90 min D2B”Standard 90 min D2B
TOO LONG !
![Page 83: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/83.jpg)
![Page 84: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/84.jpg)
![Page 85: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/85.jpg)
![Page 86: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/86.jpg)
INFERIOR WALL STEMIRIGHT CORONARY ARTERY (RCA) 75 80%-RIGHT CORONARY ARTERY (RCA) - 75-80%
- CIRCUMFLEX (CX) ARTERY – 10-15%ANTICIPATED COMPLICATIONS based on structures fed by the RCA:
- BRADYCARDIA (RCA feeds SA Node 85-90% of patients)
RIGHT VENTRICU AR MI- RIGHT VENTRICULAR MI (RCA feeds RIGHT VENTRICLE)
1st 2nd AND 3rd DEGREE HEART BLOCKS- 1st, 2nd AND 3rd DEGREE HEART BLOCKS(Dominant artery feeds AV Node)
- If POSTERIOR and/or LATERAL WALL MI present, expectIf POSTERIOR and/or LATERAL WALL MI present, expect PUMP FAILURE / CARDIOGENIC SHOCK
![Page 87: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/87.jpg)
IN EVERY CASE of
INFERIOR WALL STEMIYou must first RULE OUT RIGHT VENTRICULAR MIBy obtaining a RIGHT SIDEDBy obtaining a RIGHT SIDED ECG BEFORE giving any:
- NITROGLYCERIN- Dieuretics
![Page 88: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/88.jpg)
NITROGLYCERIN is a CLASS III CONTRINDICATION ininRIGHT VENTRICULAR MI ! !*
It WILL i it tIt WILL precipitate PROFOUND HYPOTENSION !PROFOUND HYPOTENSION !
** AHA/ACC 2013 STEMI Guidelines
![Page 89: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/89.jpg)
![Page 90: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/90.jpg)
![Page 91: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/91.jpg)
![Page 92: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/92.jpg)
![Page 93: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/93.jpg)
![Page 94: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/94.jpg)
![Page 95: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/95.jpg)
![Page 96: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/96.jpg)
![Page 97: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/97.jpg)
PatternsPatternsofISCHEMIA:
![Page 98: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/98.jpg)
![Page 99: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/99.jpg)
![Page 100: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/100.jpg)
![Page 101: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/101.jpg)
* 1. Circulation 2009: AHA/ACCF/HRS Recommendations for the Standardization and Interpretation of the ECG: Part VI: Acute Ischemia / Infarction;
2. Circulation 2013: ACCF/AHA Guidelines for Management of STEMI
![Page 102: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/102.jpg)
![Page 103: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/103.jpg)
OLD MI:OLD MI:
Within last 6 months ??
![Page 104: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/104.jpg)
From: 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: A Report of the A i C ll f C di l /A i H t A i ti T k FAmerican College of Cardiology/American Heart Association Task Force on Practice Guidelines
MACE after noncardiac surgery is often associated withprior CAD events. The stability and timing of a recent MIimpact the incidence of perioperative morbidity andimpact the incidence of perioperative morbidity andmortality.
Recent MI,defined as having occurred within 6 months of non-cardiacsurgery, was also found to be an independent risk factor for perioperative stroke, which was associated with an 8-fold increase in the perioperative mortality ratean 8 fold increase in the perioperative mortality rate
![Page 105: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/105.jpg)
From: 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on
G
A study using discharge summaries demonstrated
Practice Guidelines
that the postoperative MI rate decreased substantiallyas the length of time from MI to operation Increased. This risk was modified by the presence and type ofThis risk was modified by the presence and type of coronary revascularization (coronary artery bypass grafting [CABG] versus percutaneous coronary interventions [PCIs]) that occurred at the time of the MIinterventions [PCIs]) that occurred at the time of the MI.
T k t th th d t t th t 60 dTaken together, the data suggest that 60 days should elapse after a MI before noncardiac surgery in the absence of a coronarysurgery in the absence of a coronary intervention.
![Page 106: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/106.jpg)
![Page 107: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/107.jpg)
![Page 108: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/108.jpg)
![Page 109: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/109.jpg)
![Page 110: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/110.jpg)
![Page 111: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/111.jpg)
![Page 112: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/112.jpg)
![Page 113: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/113.jpg)
![Page 114: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/114.jpg)
![Page 115: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/115.jpg)
For Slides that are not in your handout:
ECGt i iwww.ECGtraining.org
S l t t bSelect tab: ECG ID of SADS Conditions
Then choose:Then choose:“ECG ID of SADS Conditions – PDF”
![Page 116: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/116.jpg)
BRUGADA SYNDROME A DEADLY STEMI Mimic . . . . .
![Page 117: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/117.jpg)
![Page 118: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/118.jpg)
Brugada Syndrome -- 3 ECG Patterns:
![Page 119: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/119.jpg)
Brugada / Long QT Syndromes cause:
Torsades de Pointes:Torsades de Pointes: • Decreased – to – NO Cardiac Output• Often patient PULSELESS during episodeOften patient PULSELESS during episode• Causes SYNCOPE• Often DETERIORATES into VENTRICULAR
FIBRILLATION and CARDIAC ARREST.
![Page 120: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/120.jpg)
Trigger for Torsades de Pointes – ECTOPIC BEAT duringThe “ELECTRICAL GRADIENT” phase shown above.
![Page 121: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/121.jpg)
![Page 122: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/122.jpg)
![Page 123: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/123.jpg)
![Page 124: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/124.jpg)
![Page 125: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/125.jpg)
www brugada orgwww.brugada.org
www.sads.org
www.QTsyndrome.ch
www.crediblemeds.orgg
![Page 126: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/126.jpg)
![Page 127: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/127.jpg)
![Page 128: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/128.jpg)
QT CORRECTION FORMULAS:
Bazett’s QTc=QT/ RRFredericia QTc=QT/(RR)1/3Framingham QTc=QT+0 154(1‐RR)Framingham QTc=QT+0.154(1‐RR)Rautaharju QTc=656/(1+HR/100)
![Page 129: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/129.jpg)
![Page 130: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/130.jpg)
![Page 131: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/131.jpg)
ECG Indicators of Long QT Syndrome:ECG Indicators of Long QT Syndrome:
QTc 460ms or longer in females*QTc 460ms or longer in femalesQTc 450ms or longer in males*T wave alteransU waves >100% of the T waveU waves merged with T wavesU 0 1 (1 t d d lib t dU waves >0.1mv (1mm on standard calibrated ECG)
*P. Rautaharju, et al, “Standardization and Interpretation of the ECG, Part IV” JACC2009;53, no. 11:982‐991; ,
WHEN LQTS IS SUSPECTED, TAKE THE FOLLOWING PRECAUTIONS . . . .
![Page 132: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/132.jpg)
WHEN THE “QUICK PEEK” METHOD for QT INTERAL EVALUATION IS APPLIED TO THE ABOVE ECG, WHAT IS THE RESULT?
![Page 133: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/133.jpg)
CASE PROGRESSION - 22 YEAR OLD FEMALEFEMALE:
DIAGNOSED WITH “EPILEPSY.” AllDIAGNOSED WITH EPILEPSY. All anticonvulsant medications were INEFFECTIVE atControling grand-mal seizure activity.
During visit with Electrophysiologist, patient hibit d T d d P i t d i ESTexhibited Torsades de Pointes during EST,
collapsed. DURING TDP EPISODE patient experienced “grand mal Seizure ”experienced grand mal Seizure.
ICD Implanted. ECG finding also discovered in p gpatient’s infant son. Received ICD at age 5.
![Page 134: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/134.jpg)
Brugada / Long QT Syndromes cause:
Torsades de Pointes:Torsades de Pointes: • Decreased – to – NO Cardiac Output• Often patient PULSELESS during episodeOften patient PULSELESS during episode• Causes SYNCOPE• Often DETERIORATES into VENTRICULAR
FIBRILLATION and CARDIAC ARREST.
![Page 135: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/135.jpg)
Etiology of Long QT Syndromes:C i l (14 k b )Congenital (14 known subtypes)Genetic mutation results in abnormalities of cellular ion h lchannelsAcquired
Drug InducedMetabolic/electrolyte inducedVery low energy diets / anorexiaCNS & Autonomic nervous system disordersCNS & Autonomic nervous system disorders
MiscellaneousC A t DiCoronary Artery DiseaseMitral Valve Prolapse
![Page 136: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/136.jpg)
GENETICALLY ACQUIRED LONG QT SYNDROMES:ECG PATTERNS of 3 MOST COMMON VARIATIONS:
![Page 137: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/137.jpg)
15 year old male , suffered sudden cardiac arrest. Successful out-of-hospital resuscitation with CPR / AED. His ECG is shown below:
![Page 138: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/138.jpg)
GENETICALLY ACQUIRED LONG QT SYNDROMES:ECG PATTERNS of 3 MOST COMMON VARIATIONS:
![Page 139: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/139.jpg)
EP STUDY REVEALS ABNORMAL AFTER-DEPOLARIZATION. PATIENT RECEIVED ICD.
![Page 140: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/140.jpg)
ECG recordings from leads II, aVF, and V5 in three patients from families with long QT syndrome linked to genetic markers on chromosomes 3, 7, and 11.
Moss A et al. Circulation 1995;92:2929-2934
Copyright © American Heart Association, Inc. All rights reserved.
![Page 141: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/141.jpg)
![Page 142: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/142.jpg)
Etiology of Long QT Syndromes:C i l (14 k b )Congenital (14 known subtypes)Genetic mutation results in abnormalities of cellular ion h lchannelsAcquired
Drug InducedMetabolic/electrolyte inducedVery low energy diets / anorexiaCNS & Autonomic nervous system disordersCNS & Autonomic nervous system disorders
MiscellaneousC A t DiCoronary Artery DiseaseMitral Valve Prolapse
![Page 143: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/143.jpg)
If patient has a PROLONGED Q-T INTERVAL, AVOID DRUGS THAT LENGTHEN THE Q-T.Such drugs include:Such drugs include:-Amiodarone -Ritalin-Procainamide -Benadryl-Procainamide -Benadryl-Levaquin -HaloperidolErythromycin Thorazine-Erythromycin -Thorazine
-Norpace -Propulcid-Tequin . . . . . AND MANY MORE . . . . . . . .
www torsades org & www azcert orgwww.torsades.org , & www.azcert.org
![Page 144: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/144.jpg)
PATIENT 1: NORMAL
PATIENT 2: GENETIC REPOLARIZATION ABNORMALITIES and/orPATIENT 2: GENETIC REPOLARIZATION ABNORMALITIES and/or HYPOKALEMIA is PRESENT.
![Page 145: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/145.jpg)
![Page 146: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/146.jpg)
![Page 147: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/147.jpg)
![Page 148: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/148.jpg)
![Page 149: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/149.jpg)
![Page 150: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/150.jpg)
Q: What is the idealQ: What is the ideal medication to treat Torsades?
![Page 151: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/151.jpg)
Q: What is the idealQ: What is the ideal medication to treat Torsades?
A: Magnesium Sulfate, 1 – 2 grams over 5 – 60 minutes (AHA ACLS)minutes (AHA ACLS)
![Page 152: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/152.jpg)
ABSOLUTELYABSOLUTELYNO DRUGSNO DRUGS
THATTHAT PROLONGPROLONG
THE Q-T INTERVAL ! !
![Page 153: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/153.jpg)
ECG Indicators of Long QT Syndrome:ECG Indicators of Long QT Syndrome:
QTc 460ms or longer in females*QTc 460ms or longer in femalesQTc 450ms or longer in males*T wave alteransU waves >100% of the T waveU waves merged with T wavesU 0 1 (1 t d d lib t dU waves >0.1mv (1mm on standard calibrated ECG)
*P. Rautaharju, et al, “Standardization and Interpretation of the ECG, Part IV” JACC2009;53, no. 11:982‐991; ,
WHEN LQTS IS SUSPECTED, TAKE THE FOLLOWING PRECAUTIONS . . . .
![Page 154: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/154.jpg)
Long QT Syndrome: T wave Alterans:Long QT Syndrome: T wave Alterans:
![Page 155: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/155.jpg)
ECG Indicators of Long QT Syndrome:ECG Indicators of Long QT Syndrome:
QTc 460ms or longer in females*QTc 460ms or longer in femalesQTc 450ms or longer in males*T wave alteransU waves >100% of the T waveU waves merged with T wavesU 0 1 (1 t d d lib t dU waves >0.1mv (1mm on standard calibrated ECG)
*P. Rautaharju, et al, “Standardization and Interpretation of the ECG, Part IV” JACC2009;53, no. 11:982‐991; ,
WHEN LQTS IS SUSPECTED, TAKE THE FOLLOWING PRECAUTIONS . . . .
![Page 156: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/156.jpg)
![Page 157: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/157.jpg)
![Page 158: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/158.jpg)
![Page 159: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/159.jpg)
![Page 160: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/160.jpg)
When ECG Indicators of Long QT Synrome are present:
• Obtain a thorough patient history, to rule out incidence of syncope
and family history of sudden death/ near sudden death.
• Evaluate patient’s meds list for meds that prolong the QT Interval.
• Rule out hypothermia
• Rule out CVA
• Evaluate the patient’s electrolyte levels, and
• MONITOR PATIENT’S ECG FOR RUNS OF TORSADES
C id “ l ” ( l h i l i ) l LQTS• Consider “expert consult” (electrophysiologist) to rule out LQTS
![Page 161: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/161.jpg)
When ECG Indicators of Long QT Synrome are present:
• Obtain a thorough patient history, to rule out incidence of syncope
and family history of sudden death/ near sudden death.
• Evaluate patient’s meds list for meds that prolong the QT Interval.
• Rule out hypothermia
• Rule out CVA
• Evaluate the patient’s electrolyte levels, and
• MONITOR PATIENT’S ECG FOR RUNS OF TORSADES
C id “ l ” ( l h i l i ) l LQTS• Consider “expert consult” (electrophysiologist) to rule out LQTS
LQTS + ECTOPY = Risk of Torsades de Pointes!LQTS + ECTOPY = Risk of Torsades de Pointes!
![Page 162: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/162.jpg)
Suspected LQTS Considerations include:Suspected LQTS Considerations include:
Avoidance of Meds that are known to prolong the QT f p gInterval.(refer to LIST OF MEDS KNOWN TO PROLONG THE QT INTERVAL).
![Page 163: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/163.jpg)
TREATMENT OF TORSADES de POINTESper AHA ACLS:per AHA ACLS:-TRANSIENT: MAGNESIUM SULFATE 1 – 2
gm IV infusion over 5 – 60 minutes.
-PERSISTENT, PATIENT UNSTABLE: DEFIBRILLATION (prior to 2010: DEFIBRILLATION (prior to 2010: Synchronized Cardioversion)
-CARDIAC ARREST: FOLLOW VentricularFibrillation Algorithm. b at o go t
![Page 164: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/164.jpg)
LQTS / Brugada – Anesthesia:
• Avoid Triggers of QT Prolongation and Torsades
• Maintain:Normothermia-Normothermia
- Normoxia- EuglycemiaEuglycemia- Normocarbia
• Provide Peri-op:• Provide Peri-op:- Anxiolysis- Beta Blockade- Analgesia
![Page 165: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/165.jpg)
LQTS / Brugada – Anesthesia, con’t:
• Avoid Hemodynamic Extremes:- Bradycardia / Tachycardiay y- Hypo / Hypertension
• Correct Syrum Electrolytes, especially:Correct Syrum Electrolytes, especially:- Potassium (K+)- Magnesium (Mg++)
• Prevent & Treat Dysrhythmias:- Monitor ECG in 2+ leads (II, V1, V5)( , , )- Have Defibrillator / Pacer available - Consult Cardiology as needed
![Page 166: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/166.jpg)
Anesthesia Related Drugs:g
• Midazolam has not been shown toprolong QT intervalprolong QT interval
• Propofol produces an insignificant QTl ti d t Thi t lprolongation compared to Thiopental
– Another study – shortens QT interval– Preferred agent for maintenance (TIVA)– Preferred agent for maintenance (TIVA)
• Vecuronium and Cisatracurium show noQT i l l iQT interval prolongation
• Succynlcholine consistently prolongedy y p gQT interval
![Page 167: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/167.jpg)
Anesthesia Related Drugs, Con’t:g• Reversals:– neostigmine-atropine,
d h i t i– edrophonioum-atropine,– neostigmine-glycopyrrolate
All Prolong the QT interval. . . . All Prolong the QT interval
• Droperidol 0.75mg IV and Zofran 4mg IVp g gproduced similar QT prolongation
• Droperidol 0.625mg did not produce asignificant prolongation of the QT interval,compared to saline placebo (separate study)compared to saline placebo (separate study)
![Page 168: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/168.jpg)
Volatile Agentsg• Sevoflurane, Isoflurane and Desflurane at 1MAC all prolong the QT intervalMAC all prolong the QT interval
• Halothane significantly shortens QT intervalB t H l th l iti– But Halothane also sensitizescardiac myoctyes to catecholamines
– Should be avoided in susceptible– Should be avoided in susceptiblepatients
Agents have all been administered safelywith peri-operative beta blockade, inpatients ith kno n LQTSpatients with known LQTS.
![Page 169: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/169.jpg)
Regional Anesthesiag
Study in ASA I and II male patients undergoing elective surgery under spinalundergoing elective surgery under spinal anesthesia showed significant QT prolongation after onset of blockadeprolongation after onset of blockade
![Page 170: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/170.jpg)
![Page 171: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/171.jpg)
![Page 172: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/172.jpg)
![Page 173: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/173.jpg)
![Page 174: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/174.jpg)
![Page 175: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/175.jpg)
![Page 176: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/176.jpg)
![Page 177: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/177.jpg)
Wolff-Parkinson-White + A-fib = DISASTER
![Page 178: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/178.jpg)
37 y/o male
Chief Complaint: Lightheadedness, p g ,Palpitations, Shortness of Breath
HPI: Sudden onset of above symptoms 1 happrox. 1 hour ago
PMH: HTN (non-compliant)
![Page 179: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/179.jpg)
37 y/o male
PE: Alert, oriented, restless, cool, pale, d ki PERL N JVD L ldry skin. PERL, No JVD, Lungs clear. Abd soft non tender, Extremities: WNL, no edema
Meds: None, NKDA
VS: BP 106/50, P 180, R 26, SAO2 93%93%
![Page 180: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/180.jpg)
-NOTE IRREGULARITY OF RHYTHM - (SUGGESTIVE of A-FIB)-LOOK FOR DELTA WAVES
![Page 181: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/181.jpg)
![Page 182: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/182.jpg)
Physician correctly identified Atrial Fibrillation with Rapid Ventricular Response.Ventricular Response.
Ho e er did NOT identif the WolffHowever did NOT identify the Wolff-Parkinson-White component.p
Patient was given Diltiazem –Patient was given Diltiazem –promptly converted to -VENTRICULAR FIBRILLATION.
![Page 183: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/183.jpg)
![Page 184: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/184.jpg)
![Page 185: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/185.jpg)
-NOTE IRREGULARITY OF RHYTHM - (SUGGESTIVE of A-FIB)-LOOK FOR DELTA WAVES
![Page 186: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/186.jpg)
17 year old male: W-P-W with Afib & RVR
![Page 187: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/187.jpg)
CHARACTERISTICS of W-P-W with Afib & RVR:- WIDE COMPLEX TACHYCARDIA- IRREGULARLY IRREGULAR R – R INTERVALS !!
![Page 188: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/188.jpg)
NO AV NODAL BLOCKERSNO AV NODAL BLOCKERS ( e.g. ADENOSINE, CALCIUM CHANNEL BLOCKERS)CHANNEL BLOCKERS) FOR WIDE COMPLEXFOR WIDE COMPLEX TACHYCARDIAS THAT COULDBE ATRIAL FIBRILLATION i hBE ATRIAL FIBRILLATION withPre-Excitation ( W-P-W )Pre Excitation ( W P W )
![Page 189: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/189.jpg)
Arrhythmogenic Right Ventricular Dysplasia• A genetically acquired myocardial disease associated with paroxysmal ventricular arrhythmias and sudden cardiac death.
Ch i d h l i ll b fib f l f h• Characterized pathologically by fibro-fatty replacement of the right ventricular myocardium.
• The second most common cause of sudden cardiac death in young people (after HOCM), causing up to 20% of sudden cardiac deaths in patients < 35 yrs of age.
• Typically inherited as an autosomal dominant trait with variable• Typically inherited as an autosomal dominant trait, with variable penetrance and expression (there is an autosomal recessive form calledNaxos Disease, which is associated with woolly hair and skin changes)skin changes).
• More common in men than women (3:1) and in people of Italian or Greek descent.
• Estimated to affect approximately 1 in 5,000 people overall.
![Page 190: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/190.jpg)
From: 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice G
Arrhythmogenic Right Ventricular (RV) C di th d/ D l i
Guidelines
Cardiomyopathy and/or Dysplasia:
In 1 autopsy study examining a series of 200 cases of p y y gsudden death associated with arrhythmogenic RV cardiomyopathy and/or dysplasia, death occurred in 9.5% of cases during the perioperative period Thisof cases during the perioperative period. This emphasizes the importance of close perioperativeevaluation and monitoring of these patients forventricular arrhythmia. Most of these patients requirecardiac electrophysiologist involvement and consideration for an implantable cardioverter-defibrillator p(ICD) for long-term management.
![Page 191: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/191.jpg)
ARVD ECG 1
1. “Incomplete RBBB” Pattern 4. Epsilon’s waves 2. V1, V2 Rs pattern3. Inverted T waves, symmetrical, - Global
![Page 192: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/192.jpg)
ARVD ECG 2
1. “Incomplete RBBB” Pattern 4. Epsilon’s waves 2. V1, V2 Rs pattern3. Inverted T waves, symmetrical, - Global
![Page 193: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/193.jpg)
ARVD – 12 Lead ECG Indicators
![Page 194: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/194.jpg)
![Page 195: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/195.jpg)
![Page 196: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/196.jpg)
![Page 197: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/197.jpg)
![Page 198: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/198.jpg)
![Page 199: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/199.jpg)
![Page 200: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/200.jpg)
![Page 201: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/201.jpg)
![Page 202: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/202.jpg)
![Page 203: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/203.jpg)
![Page 204: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/204.jpg)
![Page 205: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/205.jpg)
![Page 206: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/206.jpg)
![Page 207: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/207.jpg)
![Page 208: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/208.jpg)
![Page 209: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/209.jpg)
![Page 210: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/210.jpg)
![Page 211: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/211.jpg)
![Page 212: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/212.jpg)
![Page 213: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/213.jpg)
![Page 214: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/214.jpg)
![Page 215: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/215.jpg)
![Page 216: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/216.jpg)
![Page 217: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/217.jpg)
![Page 218: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/218.jpg)
![Page 219: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/219.jpg)
![Page 220: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/220.jpg)
![Page 221: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/221.jpg)
![Page 222: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/222.jpg)
![Page 223: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/223.jpg)
![Page 224: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/224.jpg)
NORMAL EJECTION FRACTION =
55 - 70%
![Page 225: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/225.jpg)
![Page 226: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/226.jpg)
![Page 227: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/227.jpg)
![Page 228: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/228.jpg)
CARDIAC VALVE DISORDERSSuch as:
•AORTIC STENOSIS
Such as:
AORTIC STENOSIS•MITRAL STENOSIS
•AORTIC REGURGITATION•MITRAL REGURGITATIONMITRAL REGURGITATION
result in CHAMBER HYPERTROPHYresult in CHAMBER HYPERTROPHY on the 12 lead ECG.
![Page 229: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/229.jpg)
When ECG Indicators of CHAMBER HYPERTROPHY Are present on the 12 Lead ECG, p ,An ECHOCARDIOGRAM shouldBe obtained and evaluated to:Be obtained and evaluated to:• CONFIRM HYPERTROPHY• DETERMINE ETIOLOGY (VALVULAR STENOSIS / VALVULAR REGURGITATION vs other etiology) . . . .
![Page 230: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/230.jpg)
![Page 231: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/231.jpg)
![Page 232: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/232.jpg)
![Page 233: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/233.jpg)
![Page 234: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/234.jpg)
![Page 235: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/235.jpg)
![Page 236: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/236.jpg)
![Page 237: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/237.jpg)
![Page 238: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/238.jpg)
![Page 239: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/239.jpg)
![Page 240: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/240.jpg)
![Page 241: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/241.jpg)
![Page 242: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/242.jpg)
![Page 243: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/243.jpg)
![Page 244: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/244.jpg)
![Page 245: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/245.jpg)
![Page 246: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/246.jpg)
![Page 247: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/247.jpg)
![Page 248: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/248.jpg)
![Page 249: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/249.jpg)
![Page 250: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/250.jpg)
![Page 251: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/251.jpg)
![Page 252: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/252.jpg)
![Page 253: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/253.jpg)
![Page 254: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/254.jpg)
![Page 255: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/255.jpg)
![Page 256: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/256.jpg)
![Page 257: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/257.jpg)
![Page 258: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/258.jpg)
![Page 259: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/259.jpg)
![Page 260: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/260.jpg)
![Page 261: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/261.jpg)
![Page 262: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/262.jpg)
![Page 263: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/263.jpg)
![Page 264: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/264.jpg)
![Page 265: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/265.jpg)
From: 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on
Valvular Heart Disease
American College of Cardiology/American Heart Association Task Force on Practice Guidelines
CLASS I Recommendations:
1 It is recommended that patients with clinically suspected moderate or greater1. It is recommended that patients with clinically suspected moderate or greater degrees of valvular stenosis or regurgitation undergo preoperative echocardiography if there has been either:
1) no prior echocardiography within 1 year or1) no prior echocardiography within 1 year or
2) a significant change in clinical status or physical examinationsince last evaluation (60). (Level of Evidence: C)
2. For adults who meet standard indications for valvular intervention (replacement and repair) on the basis of symptoms and severity of stenosisor regurgitation, valvular intervention before elective noncardiac surgery is effective in reducing perioperative risk (15). (Level of Evidence: C)
![Page 266: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/266.jpg)
From: 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice
Aortic Stenosis: Recommendation
College of Cardiology/American Heart Association Task Force on Practice Guidelines
Aortic Stenosis: Recommendation
CLASS Iia
Elevated-risk elective noncardiac surgery with appropriateintraoperative and postoperative hemodynamic monitoring is reasonable to perform in patients with asymptomatic severe aortic stenosis (AS) (48,75–84). (Level of Evidence: B)B)
![Page 267: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/267.jpg)
Hypertrophic Cardiomyopathy (HCM)
12 Lead ECG Traits:• QRS Height -- exceeds normal size, “spearing through QRS in other leads”
I t d T i lti l i (INFERIOR ANTERIOR• Inverted T waves appear in multiple regions (INFERIOR, ANTERIOR, LATERAL )• T WAVES are SYMMETRICAL (No STRAIN PATTERN noted).
![Page 268: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/268.jpg)
Hypertrophic Cardiomyopathy (HCM)
12 Lead ECG Traits:• QRS Height -- exceeds normal size, “spearing through QRS in other leads
I t d T i lti l i (ANTERIOR LATERAL )• Inverted T waves appear in multiple regions (ANTERIOR, LATERAL )• BiPHASIC T waves in Inferior Leads. • T WAVES are SYMMETRICAL (No STRAIN PATTERN noted).
![Page 269: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/269.jpg)
Typical 12 Lead ECG Indicators Suggestive of HCM:
LVHInverted T waves (predom V4-V6, II, aVF, I, L)ST Depression / Strain patternQ wavesLeft Axis DevLAE
Over 90% of patients with HCM will have an abnormal ECG.[19–21] ECG abnormalities include T wave inversion (TWI), ST segment depression, pathological Q waves conduction delay left axis deviation (LAD) and left atrialpathological Q waves, conduction delay, left-axis deviation (LAD) and left atrial enlargement (LAE).
![Page 270: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/270.jpg)
In a patient with KNOWN Hypertrophic Cardiomyopathy OR a patient with NO PREVIOUSCardiomyopathy, OR a patient with NO PREVIOUS DIAGNOSIS OF HCM who presents with an ECG like the one on the previous slide, what DIAGNOSIS of HCM . . . . . .
. . . . . . WHAT DIAGNOSTIC TEST would be most appropriate to order next ? ? ?
( HINT….we want to assess Left Ventricular function !)
![Page 271: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/271.jpg)
From: 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on
HYPERTROPHIC CARDIOMYOPATHY (HCM)
American College of Cardiology/American Heart Association Task Force on Practice Guidelines
D d t i l i t ( t i l dil t )
HYPERTROPHIC CARDIOMYOPATHY (HCM)MANAGME NT CONSIDERATIONS:
Decreased systemic vascular resistance (arterial vasodilators), volume loss, or reduction in preload or LV filling may increase the degree of dynamic obstruction and further decrease diastolicfilling and cardiac output with potentially untoward resultsfilling and cardiac output, with potentially untoward results.
Over diuresis should be avoided, and inotropicagents are usually not used in these patients because ofincreased LV outflow gradient. Studies have reportedmixed results for perioperative risk in patients with hypertrophicobstr cti e cardiom opathobstructive cardiomyopathy.
![Page 272: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/272.jpg)
Patients with HCM are at significant risk for cardiac complications during surgery and anesthesia Althoughcomplications during surgery and anesthesia. Although studies looking specifically at the pediatric population are lacking, one study of adults with HCM undergoing surgery and anesthesia found a 40% risk of experiencing at least oneand anesthesia found a 40% risk of experiencing at least one adverse cardiac event. Anesthetic management focuses on maintaining preload and afterload, avoiding increases in contractility and avoiding tachycardia. Ideally patients with HCM should be well hydrated prior to the induction of anesthesia. Agents that maintain afterload without aanesthesia. Agents that maintain afterload without a significant increase in contractility or heart rate are preferable for both induction and maintenance of anesthesia. Appropriate intra operative monitoring and a postoperativeAppropriate intra-operative monitoring and a postoperative care plan are dependent on the procedure and the severity of HCM. “Anesthetic Management of Hypertrophic Cardiomyopathy and Challenges in the MRI Suite,” Emory University School of Medicine, Children’s Healthcare of Atlanta
![Page 273: The 12 Lead ECG in PiPreoperative Cdi lCardiovascular Risk ...€¦ · Wayne Ruppert bio: 2012 –Present: BayfrontHealthDadeCityPresent: Bayfront Health Dade City Cardiovascular](https://reader034.vdocument.in/reader034/viewer/2022042916/5f567aba70dd2c7e315ca224/html5/thumbnails/273.jpg)
My top two reasons for giving everything in life the best I have to offer.Wayne W Ruppert, 352-521-1544 [email protected]