Myocardial/pericardial ECG

Question 1

Describe diagnosis of LVH

Answer 1

Requires both voltage and non voltage criteria

Voltage criteria Precordial leads

• largest R wave + largest S wave in the precordium >45mm
• R wave in v4-6 >26
• S wave in v1 + R wave in V5-6

voltage criteria in Limb leads 
R-wave in lead 1 + s wave in lead 3 > 25
R-wave in AVL > 11mm 
R-wave in AVF >20mm 
S- wave in AVR > 14mm 

Non Voltage Criteria

• Increased R wave peak time > 50 ms in leads V5 or V6
• ST segment depression and T wave inversion in the left-sided leads: AKA the left ventricular ‘strain’ pattern

Question 2

Aside from diagnosis criteria above what other ECG finding are consistant with LVH

Answer 2

Left atrail enlargement
LAD
ST elevation in v1-3 rule of appropraite discordance
Prominent U waves

Question 3

List causes of LVH

Answer 3

HOCM 
HTN 
Aortic stenosis
Mitral regurg 
Aortic regurg 
Coarctation of the aorta

Question 4

Discuss the ECG of HOCM

Answer 4

LVH criteria as above

Deep narrow q -waves inferior laterally (dagger like q) – different to q-wave in MI as <40ms in duration

Question 5

Discuss BER

Answer 5

Benign early repolarisation is an ECG pattern most commonly seen in young healthy people under the age of 50 years of age

Question 6

Discuss ECG finding of BER

Answer 6

Widespread concave ST elevation most prominent in the precordium (v2-5)

• Prominent slightly asymmetrical t-wave concordant with elevation
• Degree of STE is modest compared to the t-wave (>25%)
• STE is usually <2mm in the precordium and <0.5mm in the limb leads
• Notching at the j point - fish hook (most easily seen in V4)
• No reciprical changes
• stable over time

Question 7

Discuss ECG finding of Pericarditis

Answer 7

Widspread concave ST elevation
Nil fish hook
STE/twave ratio >0.25
Pr depression
Spodick sign - downsloping of the TP segment
Reciprical ST depression and PR elevation in AVR
STE 2>3 – suggestive of pericarditis if reversed suggestive of inferior STEMI

Question 8

Discuss ECG finding for RVH

Answer 8

RAX
Dominant R wave in V1 >7mm or RS ratio > 1
Dominant S wave in V5 or 6 > 7mm deep or R/S ratio < 1
QRS duration < 120ms

Supporting
Right atrial enlargement (p-pulmonale)
RV strain pattern – ST depression and t-wave inversion in V1-4

Question 9

Discuss causes of RVH

Answer 9

Pulmonary hypertension
Mitral stenosis
Pulmonary embolism
Chronic lung disease (cor pulmonale)
Congenital heart disease (e.g. Tetralogy of Fallot, pulmonary stenosis)
Arrhythmogenic right ventricular cardiomyopathy

Question 10

Discuss stages of pericarditis ECG

Answer 10

Stage 1 hours to days

• Pr depression
• spodick sign seen in 80% of patients
• widespread concave STE

Stage 2
-Pr and ST segments normalise which can lead to a transiently normal ECG

STage 3- days to weeks
-t-wave inversion occurs deeply inverted

Stage 4- nromalisation of the ECG
-over a period of up to 3 months however in some cases the t-wave inversion might be permanent