Upper Level Conference UNC Internal Medicine 10/21/09 Advanced EKG patterns Upper Level Conference UNC Internal Medicine 10/21/09

Basics Always examine an EKG systematically then come up with your interpretation

What is the abnormality? LVH What are the criteria for LVH? Sokolow-Lyon: V2S + V5R >= 35 Cornell: avLR + V3S > 24 in men, > 20 in women Other: avL > 11

What is the differential diagnosis for that axis? What is the axis? What is the differential diagnosis for that axis? Left Anterior Fascicular Block 1. Criteria for LAFB? LAD: LVH, inferior MI, LAFB, LBBB RAD: RVH, pul HTN/PE/COPD, LPFB, lateral MI LAFB: rS in avF, qR in I

Describe this rhythm using your “tachycardia” algorithm: What rhythm is this? How do you know? Regular, wide complex tachycardia

Any regular wide complex tachydardia: Brugada Criteria – helps you discern between VT and SVT with aberrancy If ANY of the criteria are satisfied, its VT If NO criteria is satisfied, its SVT with aberrancy

Brugada criteria Concordance in precordial leads R to S interval > 100ms in a precordial lead AV dissociation? Morphology look like VT? Concordance specifically defined as NO RS complexes in all precordial leads R to S interval specifically definied as beginning of R to deepest part of S AV dissociation specifically definied as “capture beat” or “fusion beat” For EP expert

Concordance (lack of RS complex in precordial leads)

Note capture beat

What are the abnormalities? What is the syndrome? Brugada syndrome – Inherited Na channel abnormality, can lead to sudden death Coved ST segment elevation in anterior precordial leads + TWI AICD if syncope or inducible VT on EP study

In summary Formal diagnosis of LVH LAFB and LPFB Approach to tachycardia Distinguish between VT and SVT with aberrancy – Brugada criteria Brugada syndrome