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Cardiology Board Review EKGs. Jen Streeter 4/23/19. (adapted from Dr. Harwani’s talk). Yes: Sinus, sinus tachycardia, sinus ,bradycardia, sinus with block, MAT (p up in II, but not technically sinus). Sinus (p up in II). No: Afib/flutter, SVT, VT, AIVR.
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Cardiology Board Review EKGs Jen Streeter 4/23/19 (adapted from Dr. Harwani’s talk)
Yes: Sinus, sinus tachycardia, sinus ,bradycardia, sinus with block, MAT (p up in II, but not technically sinus) Sinus (p up in II) No: Afib/flutter, SVT, VT, AIVR Regular: AIVR if HR 60-100 bpm after MI (AIVR can be as low as 40 bpm, do nothing) Irregular: Afib w aberrancy or Afib with WPW Wide Normal Regular: Sinus (HR 60-99), Afib w CHB & accelerated junctional escape (HR 60-99), AIVR if HR 60-100 bpm after MI (AIVR can be as low as 40 bpm, do nothing) Irregular: Sinus with PACs/PVCs, Afib Regular: VT if HR>100, TdP if amplitude inc/dec) Irregular: Afib with aberrancy or Afib with WPW Rate? Narrow Wide Tachy Regular: Sinus tach if Ps 1:1 QRS & HR<180, Aflutter (look in V1 for ‘P’, II/III for flutter waves, HR 1:1 300, 2:1 150, 3:1 100, 4:1 75 or variable), Afib CHB acc jcnl (no Ps, irreg baseline), SVT or (P absent or after QRS, HR>120, young female w palpitations, do vagal maneuvers, adenosine), FEAT (p not upright in II) Irregular: Afib RVR, Aflutter with variable block (look in V1, II, III), MAT (three different p wave morphologies) Narrow Brady Regular: CHB w ventricular escape (15-40 bpm), hyperkalemia Irregular: Slow Afib w aberrancy Wide Regular: sinus bradycardia, CHB w junctional escape (40-60 bpm, V rate slow and regular, A rate nl and regular, AV dyssynchrony ) Irregular: 2nddegree heart block, slow Afib Narrow Yes: Sinus w normal AV conduction PR nl? Fixed: 1stdegree AVB (hypothermia, myxedema) Long: 2nddegree AVB Mobitz 1: PR gets longer, dropped beat, then short again No Variable: Mobitz 2: Random dropped beat, or fixed interval dropped beat (2:1, 3:1, 4:1) Short: WPW (delta wave) 3rddegree AVB: 40-60 bpm, V rate slow and regular, A rate nl and regular, AV dyssynchrony Q waves Pathological if >40ms or >25% QRS amplitude and present in 2 contiguous leads. Dagger Q waves are associated with hypertrophic cardiomyopathy <120 ms (3 boxes): Normal AV conduction QRS width? >120 ms: LBBB (new LBBB+angina=STEMI), RBBB. ST segments difficult to interpret with BBB. WPW (delta wave). Wide and narrow= frequent PVCs or NSVT >440 ms (11 boxes): Long QT: congenital, psychRx/antiemetics/Abx (T waves broad), hypocalcemia (T wave duration nl), hypothermia (sinus brady, prolonged PR/QRS/QT, Osborne J wave) QTc? 360-440 ms (9-11 boxes): Normal <360 ms (9 boxes): Short QT: congenital or hypercalcemia STEMI if angina and reciprocal changes in other leads. STE in V1-V3 is anterior STEMI (LAD), in II/III/aVFis inferior STEMI (RCA), in V5-6+ST dep. V1 is posterior lateral STEMI (LCx),. Pericarditis if diffuse STE with PR depressions and positional chest pain LBBB or LVH with repolarization abnormality if no angina and STE in anterior leads Elevation ST? Normal : Depression: Ischemia if angina. UA if trop negative, NSTEMI if trop positive Ischemic if associated with STEMI/vascular territory Intracranial hemorrhage/CNS TWI if in diffuse leads LVH or HOCM if in lateral leads Deeply inverted: T? Inverted: 200 reasons Peaked: hyperkalemia (renal failure, missed dialysis) High: LVH/HOCM (large lateral Q waves, LAD, LAE, lateral TWI) Voltage? Low: Yes: Tamponade (trauma, iatrogenic, aortic dissection/aneurysm rupture, cancer, MI, myxedema, kidney failure, lupus, pericardial infection/inflammation) Electrical Alternans: No: COPD (RVH, RAD, RAE, PRWP), amyloid, myxedema (sinus brady, TW flat/inverted, long PR (can have effusion)
M RBBB: MaRRoW M in V1 W (or V) in V6 PVCs from LV have RBBB morphology W W LBBB: WiLLiaM W (or V) in V1 M in V6 PVCs from RV have LBBB morphology M
M RBBB: MaRRoW M in V1 W (or V) in V6 PVCs from LV have RBBB morphology W LBBB: WiLLiaM W (or V) in V1 M in V6 PVCs from RV have LBBB morphology
ICD CRITERIA IN HCM (1) massive myocardial hypertrophy (wall thickness ≥30 mm) (2) previous cardiac arrest due to ventricular arrhythmia (3) blunted blood pressure response or hypotension during exercise (4) unexplained syncope (5) nonsustained ventricular tachycardia on ambulatory electrocardiography (6) family history of sudden death due to HCM HOCM 8 Dagger Q waves
HOCM 9
1stdegree AV block (do nothing)
2nddegree - Mobitz I(Wenckebach) (do nothing)
2nddegree (Mobitz II) AV Block (Can progress to CHB, needs PPM)
2:1 AV Block (Can progress to CHB, needs PPM)
3rddegree AV block AKA Complete Heart Block- CHB (PPM)
Left Bundle Branch Block (STEMI if new with angina)
Right Bundle Branch Block (do nothing)
Sinus Bradycardia (do nothing unless symtomatic (SSS), then atropine and possible PPM)
Sinus bradycardia (look for/Tx underlying causes: meds/TSH/hypothermia. Only treat if symptomatic, see next slide. May need PPM)
Sick Sinus Syndrome: Tachy/Brady (PPM if symptomatic bradycardia, then BB or CCB to slow tachy)
Atrial Fibrillation with Complete Heart Block and Junctional Escape (may need PPM)
Premature Atrial Contractions (do nothing)
Premature Ventricular Contractions (get TTE, may need antiarrhythmic or ablation if severely symptomatic or causing HF, otherwise no Tx)
Sinus Tachycardia (treat underlying cause: fever, pain, anxiety, infection, PE, etc)
SVT (vagal maneuvers, adenosine, DCCV if hemodynamically unstable, refer to EP)
Afib Initial Decision Making Hemodynamically Unstable Hemodynamically Stable Urgent Cardioversion with heparin ggt or NOAC Identify and Address Reversible Causes Spontaneous Conversion Start a rate or rhythm control agent IV if HR >140, PO if HR < 140 with goal rate < 80 bpm if Sx, < 110 if no Sx Start TEE to rule out cardiac thrombus anticoagulation for 3 weeks Schedule Cardioversion Continue anticoagulation for 4 weeks or longer if necessary based on CHA2DS2 VASc
Atrial Flutter 2:1 conduction (Afib management + refer to EP)
Multifocal Atrial Tachycardia (Thought to be due to RA HTN, look for/Tx pulmonary disease. Check/replace potassium, give magnesium. Medical therapy for MAT is indicated if sustained RVR that causes or worsens myocardial ischemia, heart failure, peripheral perfusion, or oxygenation)
AV Node Reentrant Tachycardia (AVNRT) (vagal maneuvers, adenosine, DCCV, refer to EP)
Focal Ectopic Atrial Tachycardia- FEAT (ectopic focus is not the SA node so P wave are not upright in II, usually upright in V1)
Common causes of PEA Arrest: Hypovolemia (dialysis, internal bleeding) Hypoxemia Order: Finger stick glucose, STAT Lactate/BMP/CBC/LFTs, troponin, BNP, review drugs(˄QT, K, opiates, OD, OCP)/get levels. Review chart for Hs/Ts risk factors. After Rosc, consider TTE, EKG, CXR, art line/ABG, central line/SVO2, CTA chest(PE)/ab/pel(bleeding), cors
Frequent PVC’s (1-2 beats) and Nonsustained Ventricular Tachycardia 3 beats – 30 sec)
Torsades de Pointes Torsades de Pointes
LVH with Repolarization Abnormalities or Hypertrophic Cardiomyopathy
Tamponade (low voltage with electrical alternans)
Posterolateral Acute Infarction (Left Circumflex)
Pericarditis (Diffuse ST elevation with PR depression and positional chest pain, maybe viral prodrome or recent new med)