OSCE- ECG

Phase IIIa

sienmingoat

Dizziness

Ventricular tachycardia• Describe?

– regular widen/bizarre QRS (> 0.14 s or 3.5 small squares)– QRS rate: 140-200 beats/min – P not present/dissociated/retrograde (AV dissociation)

– Indeterminate QRS axis– Concordant pattern (all +/- polarity) in lead V1-V6– Sinus capture/fusion beats (different morphology)– LBBB pattern (also SVT w aberrant ventricular conduction)

• Causes: – CAD/IHD/MI– Cardiomyopathy (hypertrophic, dilated), mitral valve prolapse– Digitalis intoxication

• CX?– V fibrillation– Hypotension

• Rx (avoid VF)– Amiodarone - DC cardioversion– IV lignocaine - pacing– IV procaineamide– Cardioversion

• S&S?– Hemodynamic instability: hypotension, pul edema, cardiac arrest– Presyncope/dizziness or syncope (dizziness, palpitation, syncope, cardiac arrest)

64yo man, A&E with syncope. Admission ECG.

Inferior MI• Dx?

– Acute Inferior MI (with posterior infarction)

• Describe/List abnormalities?– II, III, aVF changes (IMI)

• Q waves present• ST elevation

– I, aVL (hyperacute transmural IMI)• tall T• Reciprocal ST depression

– V1-V4 (PMI)• Reciprocal ST depression

• What artery?– R coronary artery

• Risk Factors (modifiable)– Smoking– Hypercholesterolemia– DM– HPT

MI- Presentation?

• symptoms: acute central chest pain, SOB, sweatiness, palpitation

• signs: anxiety/distress, pallor, abn pulse/BP, hear failure/murmur

MI- complication?

• Cardiac arrest

• Cardiogenic shock

• Heart block

• DVT/PE/thromboembolism

• Valvular heart dz

• Cardiac tamponade/pericarditis

Posterior MI

• Reciprocal changes in leads V1-V3

• Dominant R in leads V1-V3

• ST segment depression in leads V1-V3

• Tall, upright T wave in leads V1-V3

38yo lady, SOB palpitation 1 week

Atrial fibrillation • What is the rhythm?

– Irregularly irregular: Atrial fibrillation

• 2 abnormalities?– Disorganized indistinct P– ‘f’ wave (irregular/undulating baseline)– Rapid/slow ventricular rate?

• 4 causes– IHD– CHF– HPT– Thyrotoxicosis– Mitral valve dz (MS/MR)– Idiopathic

• 1 complication– Stroke (systemic thrombo-embolism)

• Mnagement:– Digoxin (B-blocker)/verapamil: if high ventricular rate– Anti-coagulant

Palpitation, X organic HD

SVT (AVNRT)

• Describe?– Regular narrow complex tachycardia (>170)– P absent – P inverted @ II(b4/aft/in QRS)

• Why neck massage?– Carotid sinus massage (vagotonic stimuli) – Transient increase AV block– Unmask u/lying atrial rhythm– Alternative: adenosine/valsalva maneuver

• Components:– AV nodal re-entrant T– AV reciprocating T (WPW syndrome)– Atrial T – Junctional/nodal T

70y/o chest pain

Left ventricular hypertrophy

• 3 abnormalities?– S @ V1-V2 + R @ V5-V6 > 35mm– V5-V6 & I: ST depression & T inversion (L

wall ischemia)• S wave > 25 mm in V1 or V2• R wave > 25mm in V5 or V6• The sum of R wave in V5/6 and S wave in V1/2 > 35mm

• Diagnosis/cause?– Angina 2nd to IHD

Ventricular hypertrophy with strain

• ST segment depression

• T wave inversion

Right ventricular hypertrophy

• Dominant R in V1

• Deep S in V5 and V6

• RAD

• RBBB

Anterior MI

• Abnormalities?– Pathological Q @ V1-V3– ST segment elevation V1-V6, I, aVL

• Diagnosis?– Acute extensive anterior MI

• Artery involved?– L anterior descending artery

• Risk factor?– DM– Smoking– Elderly– Hypercholesterolemia– Hypertension

58yo female, hip fracure + recurrent syncope/dizzy

Third degree AV block• Atrial rate?

– 300/3.5= 85 bpm

• Ventricular rate?– 300/10= 30 bpm

• Relationship btw A-V?– Complete atrio-ventricular dissociation (3rd degree)

• Reson for syncope?– Bradycardia d2 3rd degree AV block (Stokes-Adams attack)

• Physical signs?– Bradycardia– Cannon a wave– Dizziness/syncope/SOB (exertion)– Postural hypotension

• Causes?– IHD/post-MI– idiopathic fibrosis– Drug toxicity (digoxin/B-blocker)– Infiltrative process (amyloidosis, sarcoidosis)– Connective tis dz (SLE/RA)– Endocarditis/Myocarditis– Congenital– NM disorders (Duchenne MD)

Adams-Stokes syndrome

slow or absent pulse, vertigo, syncope, convulsions, and sometimes Cheyne-Stokes respiration; usually as a result of advanced A-V block or sick sinus syndrome

Acute Pericarditis• Description?

– ST elevation @ II (max), V1-V6 (saddle-shaped/concave upward)– ST depression @ aVR, ST iso @ aVL (ST vector directed to lead II)– PR depression @ II (max), V1-V6 (acute)– Normal QRS voltage & T

• Diagnosis?– Acute pericarditis

• DDX ST elevation?– Transmural infarct– Early repolarization syndrome (Grusin pattern II)– Acute pericariditis

• S&S?– Chest pain

• sharp retrosternal• Worse on inspiration• relieved by sitting fwd• Radiate neck + shoulder

– Pericardial friction rub

• Rx?– NSAIDs

VS chronic:

• low voltage

• low/isoelectric T (all except aVR)

Mitral stenosis

• 3 findings: – RAD– P mitrale @ II (bifid P) RVH

• Causes?– MS

• Cx– AF– Lung ifx– Cor pulmonale/pul HPT– IE– Thromboembolism– RVH/TR

56yo palpitation 1 day

Atrial flutter

• Cardiac rhythm?– Atrial flutter with variable degrees AV-nodal block– sawtooth/F waves

• 2 other abnormalities?– Reverse tick = digitalis use– Regular tachycardia (if 2:1 block)– narrow QRS

• 3 causes?– CVS: IHD, HPT, chronic rheumatic valvular dz– Others: sepsis, atrial enlargement, digoxin,

thyrotoxicosis

Atrial tachycardia

• Describe?– Tachycardia (regular narrow QRS)– Clear visible P wave precedes each QRS– RP interval longer/equal PR interval (VS: AV

reciprocating tachycardia)– (criteria: heart rate >100, abnormal p wave)

• Causes?– Digoxin toxicity– IHD, RHD, cardiomyopathy– Sick sinus syndrome– COPD