ECG cases Flashcards
longstanding progressive SOB with distended neck veins in a smoker
RAH - p pulmonale in II,III
RVH - R wave in v1 and S in v5
Likely cor pulminale due to COPD
Chest pain. Territory? What is the ectopic?
Anteriolateral infarction (q waves present)
SVE - Has preceeding p wave
74 long term warfarin and worsening of SOBOE. Has loud systolic murmur on exam.
2 things on ECG ?
Diagnosis?
AF
LVH with strain
Likely aortic stenosis
chest pain yesterday
2:1 AV block
Inferior MI - Q waves
71F Hyperthyroid on carbimazole. AF on digoxin and NOAC. ECG shows?
AF
Digitalis effect - with salvador Dali sagging
Downsloping ST depression with a characteristic “reverse tick” or “Salvador Dali sagging” appearance
Flattened, inverted, or biphasic T waves
Shortened QT interval
Here is sagging reverse tick
What drug are they taking
Digoxin
Salvador dali ST sagging
Describe the ST segments
Reverse tick sign - digoxin
Chest pain yesterday. Now in ED feeling dizzy
Whats on the ECG
3rd degree AV block with junctional escape
Inferior infarction- Q Waves and STE as well as reciprocal ST depression v1
[junctional area likely close to bundle of his as QRS complexes normal length]
80F chest pain
Where is lesion? Block?
Inferior STEMI
1st degree AV block
56M severe chest pain
Anteriolateral ischemia STEMI with reciprocal changes
What type of pacing?
Which type of block do paced rhythms look like?
What if it looked like the other?
AV sequential pacing
Look like LBBB
As pacing lead is in Right ventricle -> impulse travels from RV
If looked like RBBB
Concerning as possible pacing lead has eroded through septum and pacing from LV
29m sudden onset Chest pain after cocaine but negative trop. Now entirely resolved
Coronary artery vasospasm
Which pacing type? usually due to?
Atrial pacing
Sick sinus syndrome
73 SOBOE
Atrial Flutter
How fast are most flutter waves?
0.2s
300/min usually
25M chest pain with sore throat and pyrexia
Pericarditis
Widespread STE saddle
83F collapse. Found at home 11hrs later. What is wrong?
Hypothermia
j waves - slight positive delfection of ST segment at j point
AF
Borderline prolonged QT
81F CP
Posterior STEMI
24m healthy whats seen
Lead misplacement
Appears to show
- RAD
- Upright t waves in aVR
- Negative p and t waves aVL
22m palps prev normal ECG
AVNRT
Regular narrow complex rate approx 200
[200 and regular unusual if flutter]
79 SOB which pacing?
ventricular
86F SOB dizzy and syncope
MI 2/12 and t2dm
3rd degree HB
77f presyncope for 1 month
2:1 second degree block
72f SOBOE and orthopnea
Prev MI with impaired LVEF + essential tremor
NSM with tremor in limb leads
73M SOB and oedmea
HTN and COPD
LVH and RVH
RVH - Dominant R wave v1 and >7mm
28m palps
Artefact
Which operation
Heterotopic heart transplant
New heart from donor
[orthotopic - own heard removed
heterotopic - own heart left when donor heart transplanted]
83m VVI pacemaker presents with dizziness
Pacemaker failing to capture
5 pacing spikes
2 paced QRS (in blue)
3 failed (yellow)
What is this ectopic
R on T ventricular ectopic
63 D&V and abnormal electrolytes.
Now syncope
Polymorphic VT
likely secondary to prolonged QT
77f haematemesis and melena
What rhythm?
Sinus tachy with aberrant conduction
p waves visible in v1/2
LBBB pattern - creates the wide QRS
73m syncope
SA block
In block the area where the p p interval is constant with 1 or 2 missed beats
In SA arrest the interval will not match a predicted P P interval
Looking at just p waves
Top - Sinus Rythm
Middle - SA block
Bottom Sinus arrest
57f SOB following hip operation
Sinus tachy
RSR in III and v1.
negative T waves in R sided precordial leads
-> RV strain
= PE
57F sudden onset palps
AF with ventricular prexcitation
Irregular rythm
78m why are the T waves negative
NSR
Wide QRS LBBB and notched R in 1
Note LBBB resolves after 1st half ECG
-> Expect TWI following LBBB dissolution
56M palps
mobitz type 1 with atrial ectopics
[dont mix up the p and the t waves]
46F anxious and presyncopal episodes
AV dissocation
34M routine check up for insurance
Short PR
Big R waves v1 and throughout
[no deep S waves in v5/6 so not RBH]
d waves
= WPW
77F syncopal episodes
RBBB RSR v1
LAD
1st degree AV block
= trifasicular block (but not complete heart block)
74F on digoxin nausea and vomiting
Atrial tachy (rate approx 190) with a 2::1 AV block
76F IHD CP and SOB
ECG demonstrates?
How can you be sure its not SVT with aberrant conduction ?
monomorphic VT
Very broad QRS >160ms
Positive complexes V1-6
No LBBB/RBBB
History suggestive
independent p wave activity
52m anteriolateral STEMI thrombolysed
Now
First half
Idioventricular rhythm
[Often seen post reperfusion]
Then SR
[Idioventricular rhythm starts in your ventricles or lower chambers.
Junctional rhythm begins at the junction of your upper and lower heart chambers.]
80m SOB
which rhythm?
Which medication would you be suspicious of?
Atrial tachy with variable block
Note inverted p waves in eg v2-v3 and inferior leads
Upright p waves in v1
[Indicates an ectopic focus in the atria (travelling away from inferior leads)]
Digoxin - reverse tick sign in inferiolateral leads.
Atrial tachy with variable block is also a side effect of toxicity
58M smoker
Palps and dizziness -> given adenosine
Atrial flutter
71m asymptomatic
p waves precede each QRS (circled blue)
Additonal p waves (circled red) which have no relationship to QRS
-> Ectopic focus firing at different rate to SA node
=Atrial parasystole
[Generally benign condition]
24m Dizzy and chest pressure for 6 months ?
What test to identify?
RSR and TWI in v1/2
?Brugada / other Sodium chanelopathy
Ajmalin test
-See unmasking of STE in v1-3
Widening of QRS
Note R on T ectopic at start of tracing (worry as may progress to VT)
Whats this ectopic
AF with Ashman phenomenon
Ashman - aberrant conduction of QRS complex when you have a short RR interval following a long RR interval
-Usually RBBB appearance
-Comes from supraventricular focus
Due to a variability in the refratory period in the ventricular (right bundle) conduction system (following the long RR interval)
29m collapse at home
Brugada - Type 1
R sided leads
-RBBB morphology
-STE +/-TWI
How can you increase sensitivity of brugada ECG? What causes it?
Test if your unsure ?
Leads v1/v2 in 2nd rather than 4th intercostal space
Caused by mutation Na channel (SCN5a)
-Autosomal dominant
ajmaline / flecainide challenge - unmasks appearance
3 types of brugada on ECG?
type 1
-Coved STE with inverted T waves
Type 2
-Saddle shaped STE with positive / biphasic t waves
-Terminal portion of ST segment >1mm raised
type 3
-Saddle shaped STE with positive T waves
-Terminal portion ST segment <1mm raised
29m Collapse at home
Brugada Type 2
[has >2mm of saddleback shaped ST elevation]
29m collapse at home
Brugada type 1
-Coved ST segment elevation >2mm in >1 of V1-V3 followed by a negative T wave.
Chest pain
ST elevation is present throughout the precordial and inferior leads
There are hyperacute T waves, most prominent in V1-3
Q waves are forming in V1-3, as well as leads III and aVF
This pattern is suggestive of occlusion occurring in “type III” or “wraparound” LAD (i.e. one that wraps around the cardiac apex to supply the inferior wall
