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ECG Underwriting Puzzler

ECG Underwriting Puzzler. Presented by: William Rooney, M.D. Obtaining Best Results from this presentation. For best results—please do the following: Select “Slide Show” from the menu option on top. Select “From the beginning”. Slowly click through the presentation Have fun!---Good luck.

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ECG Underwriting Puzzler

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  1. ECG Underwriting Puzzler Presented by: William Rooney, M.D.

  2. Obtaining Best Results from this presentation For best results—please do the following: Select “Slide Show” from the menu option on top Select “From the beginning” Slowly click through the presentation Have fun!---Good luck

  3. QUESTION????What is the major abnormality on this ECG? Week 13 in the “Case of the Week” series OK, fine. There are several abnormalities. So, how about rhythm abnormalities? 3

  4. Analysis Week 13 in the “Case of the Week” series CLUE: Look for the p waves P waves are hard to find huh. How about the regularity of the rhythm? Irregularly irregular….what could cause that appearance?

  5. Reviewing the Disorder Week 13 in the “Case of the Week” series 2 1 1 3 The intervals are all different You are right if you said Atrial Fibrillation 2 3 Measure the R-R interval Notice that they have no identifiable repetitive pattern Don’t get confused if you observe electrical activity in some leads suggestive of p waves but no distinct p waves are found such as is seen in V6. Baseline artifact is common and can be confusing. 5

  6. Animation of the disorder Here is a diagram of the normal conduction system of the heart Ectopic foci This is animation trying to depict a normal SA node generated beat in the atrium SA NODE AV NODE Ectopic foci can develop anywhere in the atrium and can compete with the normal SA node When multiple ectopic foci are present it can get chaotic This animation tries to depict atrial fibrillation competing with the normal SA node in the atrium The AV node is stimulated repeatedly from different focus. It irregularly allows an impulse through causing an irregularly, irregular heart rate Atrial fibrillation occurs when there are multiple irritable automaticity foci in the atria

  7. ECG features of this disorder Features Features of atrial fibrillation No discrete P waves F waves (fibrillatory) are present sometimes No repetitive pattern to the RR interval Ventricular rate typically between 90-170 beats/min when untreated. QRS complexes are typically narrow (although they can be wider if other conditions are associated with it --such as bundle branch block) 7

  8. Final Thoughts - ECG Solved Week13 in the “Case of the Week” series Other abnormalities on this ECG: (Just to be complete) Q waves in leads III and aVF suggestive of but not diagnostic of an inferior wall MI Extensive “minor” T wave changes with low/flat T waves noted in the inferior and lateral leads as well as leads V4-6. Leftward axis CAUTION: Other conditions which have irregularly irregular R-R intervals include: Multifocal atrial tachycardia Multifocal atrial premature beats Atrial tachycardia or atrial flutter with varying AV block This concludes this edition of the ECG puzzler. Contact me if you have questions! For further reading: Please see page 110 in Dale Dubin’s 6th edition of Rapid Interpretation of EKG’s

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