Beyond the basics Quiz Q1 55 year old man presents with central crushing chest pain Comment on the ECG and what is you treatment plan Quiz Q1 Quiz Q2 78 year old diabetic man Previous MI Presents with sudden onset SOB and an odd feeling in chest ID: 932287
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Slide1
Alastair Jones
ADVANCED ECGs
Beyond the basics…
Slide2Quiz Q155 year old man presents with central crushing chest pain.Comment on the ECG and what is you treatment plan?
Slide3Quiz Q1
Slide4Quiz Q278 year old diabetic man. Previous MI. Presents with sudden onset SOB and an odd feeling in chest.Comment on the ECG and what is you treatment plan?
Slide5Quiz Q2
Slide6Quiz Q345 year old male. Brought in by wife after an episode of severe indigestion last night. Now symptoms free. Insists he’s fine and wants to go home. Thinks his wife is worrying unnecessarily.Obs fine. Bloods normal. Trop negative.Comment on the ECG and what is your management plan?
Slide7Quiz Q3
Slide8Quiz Q478 year old lady who presents with ischaemic chest pain.Comment on the ECG.How can you confirm your diagnosis and what is your management plan?
Slide9Quiz Q4
Slide10Quiz Q520 year old student. Brought in after collapse.Went to feel lightheaded and then blacked out for a few seconds.Not happened before. Now feels fine and wants to go home.Comment on his ECG and what would you tell him?
Slide11Quiz Q5
Slide12Quiz Q6VT OR SVT?
Slide13Quiz Q6
Slide14Elevation in aVR
Slide15Elevation in aVRSingle lead - significant?Yes. STE in aVR implies lesion of the left main coronary artery
Slide16Elevation in aVRSTE in aVR itself of more than 1.5 mm carries a 75% specificity of LMCA and ~75% mortality! STE in aVR + avL -- 90% specificity AMISTE in aVR + V1 -- suggestive either prox LAD or LMCA occlusion butSTE in aVR > V1 -- more suggestive of LMCAThe significance of STE in aVR is dubious in the presence of BBB.
Slide17Sgarbossa Criteria Or how to detect AMI in LBBBST elevation ≥1 mm in a lead with upward (concordant) QRS complex - 5 pointsST depression ≥1 mm in lead V1, V2, or V3 (concordant) - 3 pointsST elevation ≥5 mm in a lead with downward (discordant) QRS complex - 2 points≥3 points = specificity of 98% and sensitivity of 20% (10 paper meta-analysis of 614 patients)
Slide18Sgarbossa Criteria
Slide19Sgarbossa Criteria Only one lead required BUT the significance of elevation in aVR is no longer certain.Serial / old ECG’s can also help
Slide20Wellens’ SyndromeWellens’ syndrome is a pattern of inverted or biphasic T waves in V2-3 (in patients presenting with ischaemic chest pain) that is highly specific for critical stenosis of the left anterior descending artery.Patients may be pain free by the time the ECG is taken and have normally or minimally elevated cardiac enzymes; however, they are at extremely high risk for extensive anterior wall MI within the next 2-3 weeks.Type 1 Wellens’ T-waves are deeply and symmetrically invertedType 2 Wellens’ T-waves are biphasic, with the initial deflection positive and the terminal deflection negative
Slide21Wellens’ Syndrome - Type 1
Slide22Wellens’ Syndrome - Type 2
Slide23Wellen’s Syndrome Wellen's criteria is not dependent on ST changes, just the T inversion!VERY worrying...Signifies critical LAD stenosis!100% of 180 patients with the pattern having >50% stenosis of the left anterior descending coronary artery (mean = 85%), with complete or near complete occlusion in almost 60%.Likely to need a cath lab rather than medical therapy...Should be investigated urgently even if now asymptomatic!BUT - young children and especially female up to 40 years, may have normal variant of T inversion (the juvenile pattern).
Slide24Posterior MI
Slide25Posterior MIBe wary in any patient with infero-lateral ischaemia.Posterior MI is suggested by the following changes in V1-3:Horizontal ST depressionTall, broad R waves (>30ms)Upright T wavesDominant R wave (R/S ratio > 1) in V2
Slide26Posterior MIPosterior Leads:V7 – Left posterior axillary line, in the same horizontal plane as V6.V8 – Tip of the left scapula, in the same horizontal plane as V6.V9 – Left paraspinal region, in the same horizontal plane as V6.
Slide27Posterior MI
Slide28Posterior MIThe degree of ST elevation seen in V7-9 is typically modest – note that only 0.5 mm of ST elevation is required to make the diagnosis of posterior MI!
Slide29Posterior MI
Slide30Posterior MI
Slide31Brugada Syndrome25 year old Asian male has had a collapse. Now feels fine and wants to go home...
Slide32Brugada SyndromeBrugada syndrome is an ECG abnormality with a high incidence of sudden cardiac death in structurally normal hearts...Sodium channel mutation (at least 60 different types described so far)Diagnosis depends upon ECG criteria (which may be transient and clinical criteria (VF, VT, syncope, FHx sudden cardiac death <45)Definitive treatment = ICD
Slide33Brugada SyndromeMay be unmasked / augmented by the following:FeverIschaemiaMultiple Drugs: Sodium channel blockers (eg Flecainide, Propafenone), Calcium channel blockers, Alpha agonists, Beta Blockers, Nitrates, Cholinergic stimulation, Cocaine, AlcoholHypokalaemiaHypothermiaPost DC cardioversion
Slide34Brugada Syndrome - Type 1
Type 1: Coved ST segment elevation >2mm in >1 of V1-V3 followed by a negative T wave (don’t confuse with RBBB which should have ST depression)
Slide35Brugada Syndrome - Type 2
Type 2 has >2mm of saddleback shaped ST elevation.
Slide36Brugada Syndrome - Type 3
Brugada type 3 can have either type 1 or type 2 morphology, but with <2mm of ST segment elevation.
Slide37Brugada SyndromeDo they need admitting?Type 1 ECG and symptomatic = YES!If undiagnosed - 10% mortality per year...Asymptomatic patients with a type 1 ECG pattern and all type 2 + 3 ECG patterns can probably go home and have outpatient electrophysiology...
Slide38Brugada Syndrome...however, EPS is far from a gold standard, with a negative predictive value of less than 50% and some studies suggest that we might be getting a little over-excited about this relatively recently described ECG finding (1992).One study followed 98 asymptomatic japanese patients with a type 1 ECG found incidentally for 7.8 years and found them to have no greater mortality than the rest of a 14000 strong cohort. This highlights the importance of the clinical criteria required for diagnosis listed above.
Slide39Trifasicular blockDisease in all 3 conduction fasicles (RBB, LAF, LPF)May be complete or incomplete:Incomplete (or Impending) – RBBB, LAD, 1st degree HBComplete – 3rd degree HB and bifasicular block (usually RBBB and LAD)
Slide40Trifasicular block (incomplete)
Slide41Trifasicular blockIncomplete trifascicular block may progress to complete heart block.Patients who present with a syncopal episode and have an ECG showing incomplete trifascicular block should be admitted for a cardiology review as they may be having episodes of complete heart block. Therefore, some of these patients will require a pacemaker.
Slide42VT or SVT with aberrant conduction???
Slide43VT or SVT with aberrant conduction???3 possibilities:VTSVT with aberrant conduction due to bundle branch blockSVT with aberrant conduction due to the Wolff-Parkinson-White syndrome
Slide44VT or SVT with aberrant conduction???While it is not always possible to differentiate VT from SVT with aberrant conduction it is important to try. SVT is amenable to AV nodal blockers. But someone in VT can suffer haemodynamic collapse if AV blockers given...Unfortunately, the electrocardiographic differentiation of VT from SVT with aberrancy is not always possible. However, there are several electrocardiographic features that increase the likelihood of VT:
Slide45More likely to be VT...Absence of typical RBBB or LBBB morphologyExtreme axis deviation (“northwest axis”)Very broad complexes (>160ms)AV dissociation (P and QRS complexes at different rates)
Slide46More likely to be VT...Capture beats — occur when the sinoatrial node transiently ‘captures’ the ventricles, in the midst of AV dissociation, to produce a QRS complex of normal duration.Fusion beats — occur when a sinus and ventricular beat coincides to produce a hybrid complex.
Slide47More likely to be VT...Brugada’s sign – The distance from the onset of the QRS complex to the nadir of the S-wave is > 100msJosephson’s sign – Notching near the nadir of the S-wave
Slide48More likely to be VT...Positive or negative concordance throughout the chest leads, i.e. leads V1-6 show entirely positive (R) or entirely negative (QS) complexes, with no RS complexes seen.RSR’ complexes with a taller left rabbit ear. This is the most specific finding in favour of VT. This is in contrast to RBBB, where the right rabbit ear is taller.
VT
RBBB
Slide49The likelihood of VT is also increased if:Age > 35 (positive predictive value of 85%)Structural heart diseaseIschaemic heart diseasePrevious MICongestive heart failureCardiomyopathyFamily history of sudden cardiac death (suggesting conditions such as HOCM, congenital long QT syndrome, Brugada syndrome or arrhythmogenic right ventricular dysplasia that are associated with episodes of VT)
Slide50The likelihood of SVT with aberrancy is increased if:Previous ECGs show a bundle branch block pattern with identical morphology to the broad complex tachycardia.Previous ECGs show evidence of WPW (short PR < 120ms, broad QRS, delta wave).The patient has a history of paroxysmal tachycardias that have been successfully terminated with adenosine or vagal manoeuvres.HOWEVER - IF IN DOUBT TREAT AS VT
Slide51Quiz Answers Q155 year old man presents with central crushing chest pain.Comment on the ECG and what is you treatment plan?
Slide52Quiz Answers Q1
Slide53Quiz Answers Q1NSRWidespread ST depressionElevation in aVR --> LMCA lesion!!D/W Papworth for ?PPCI, ACS Rx etc…
Slide54Quiz Answers Q278 year old diabetic man. Previous MI. Presents with sudden onset SOB and an odd feeling in chest.Comment on the ECG and what is you treatment plan?
Slide55Quiz Answers Q2
Slide56Quiz Answers Q2Paced rhythm - Broad complexesPositive Scarbossa Criteria> 5mm ST elevation in III, aVF< 1mm ST depression V2, V31mm ST elevation aVLNeeds PPCI
Slide57Quiz Answers Q345 year old male. Brought in by wife after an episode of severe indigestion last night. Now symptoms free. Insists he’s fine and wants to go home. Thinks his wife is worrying unnecessarily.Obs fine. Bloods normal. Trop 12.Comment on the ECG and what is your management plan?
Slide58Quiz Answers Q3
Slide59Quiz Answers Q3Wellens’ type 1 - deep symmetrical TWI anteriorly.Likely has a severe LAD stenosis and should be investigated urgently. Refer medics for urgent angiography.
Slide60Quiz Answers Q478 year old lady who presents with ischaemic chest pain.Comment on the ECG.How can you confirm your diagnosis and what is your management plan?
Slide61Quiz Answers Q4
Slide62Quiz Answers Q4Likely posterior MI (borderline inferior MI also)Anterior ST depression with a dominant R wave.Confirm with posterior leadsTreat as per AMI - PPCI
Slide63Quiz Answers Q520 year old student. Brought in after collapse.Went to feel lightheaded and then blacked out for a few seconds.Not happened before. Now feels fine and wants to go home.Comment on his ECG and what would you tell him?
Slide64Quiz Answers Q5
Slide65Quiz Answers Q5Brugada syndrome type 1Risk of sudden death. Need admission for an ICD...
Slide66Quiz Answers Q6VT OR SVT?
Slide67Quiz Answers Q6
Slide68Quiz Answers Q6Probably SVT with aberrant conduction.
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