INTERPRETATION of ELECTROCARDIOGRAMS

1. INTERPRETATION of ELECTROCARDIOGRAMS BRIAN D. LE, MD Presbyterian Hospital CIVA

2. Outline • Approach to interpretation of ECGs • Cases illustrating approach principles • Unusual Cases

5. Seven Step Approach • Rate • Rhythm • Axis • Intervals • Hypertrophy • ST/Tw changes, Q waves • Conduction system

6. Seven Step Approach • Rate • Rhythm • Axis • Intervals • Hypertrophy • ST/Tw changes, Q waves • Conduction system

8. Seven Step Approach • Rate • Rhythm • Axis • Intervals • Hypertrophy • ST/Tw changes, Q waves • Conduction system

11. Seven Step Approach • Rate • Rhythm • Axis • Intervals • Hypertrophy • ST/Tw changes, Q waves • Conduction system

14. Seven Step Approach • Rate • Rhythm • Axis • Intervals • Hypertrophy • ST/Tw changes, Q waves • Conduction system

15. INTERVALS PR < 200 ms QRS < 120 ms QTc: Men < 440 ms, Women < 460 ms

16. Seven Step Approach • Rate • Rhythm • Axis • Intervals • Hypertrophy • ST/Tw changes, Q waves • Conduction system

17. Left Ventricular Hypertrophy • Cornell +R (aVL)+Sw(V3)>24mm (male) >20mm (female) • Sokolow S(V1) + R(V5)=32mm • Rw (aVL)>11mm • Rw (I)>14mm

18. Right Ventricular Hypertrophy • 1. RAD>100* • 2. IRBBB • 3. R>S V1 • 4. R<S V6 • 5. R in V1>=7mm • 6. R V1 + S V5 or V6 >=10mm • 7. RAE • 8. strain pattern in rt precordial leads

19. Seven Step Approach • Rate • Rhythm • Axis • Intervals • Hypertrophy • ST/Tw changes, Q waves • Conduction system

20. ANATOMICAL LOCALIZATION ANTERIOR: V1-V4, SEPTAL V1-V2 LATERAL: V5-V6, I, Avl INFERIOR: II, III, aVF

21. Seven Step Approach • Rate • Rhythm • Axis • Intervals • Hypertrophy • ST/Tw changes, Q waves • Conduction system

24. LBBB • QRS > 0.12 sec • wide monophasic R in I, V5 and V6 • (usually notched or slurred) • no Q in I, V5 and V6 • Left Anterior Fascicular Block • LAD > -30', + I, aVR, -II/III/aVF • qR in I and L • rS in II, III and aVF • Left Posterior Fascicular Block • RAD > 100' • small R in I and aVL, Q in II, III, aVF • S1 Q3 pattern • RBBB • QRS>0.12 sec • R' > r in right precordium • wide S in I, V5 and V6

25. Normal Variants- Juvenile Tw inversions

26. Nuts and Bolts

27. Electrode Misplacement

28. Amplitude Artifact

29. Parkinson’s Tremor

30. CASES

31. Case 1: 21 yo presents for routine physical exam

32. DEXTROCARDIA

33. Case 2: 38 yo with one week of URI presents with chest pain

34. Acute Pericarditis • Stage I--ST elevation, Tw upright, • PR depression • Stage II--ST baseline, flattened Tw • Stage III--inv Tw • Stage IV--Tw baseline, days to wks

35. Case 3: 48 yo homeless man found unresponsive

36. Hypothermia

37. Case 4: 34 yo ESRD missed three days of dialysis

38. Hyperkalemia

39. Case 5: 28 yo woman s/p neck surgery

40. Hypocalcemia

41. Case 6: 32 yo female on antidepressants had syncope

42. Acquired Long QT Syndrome

43. Case 7: 60 yo man with chest pain

44. Inferior MI with RV infarction and 2:1 and complete heart block

45. 2:1 Heart block with ventriculophasic effect

47. Case 8: 80 yo man with syncope

48. Aflutter with complete heart block Aflutter with complete heart block Aflutter with normal conduction

49. Aflutter with 1:1 conduction

50. Aflutter with carotid sinus massage