Electrocardiogram Interpretation: A Brief Overview Wissam Alajaji, MD

Basic principles for ECG interpretation Normal ECG Objectives: Basic principles for ECG interpretation Normal ECG Abnormal ECG examples 13 slides Know that This presentation will not cover “ECG dilemmas” Should you code Q wave in V1, V2 or only when it involves all V1, V2, V3.” A: only when V3 is involved “in LBBB should you code acute MI?” A: No Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Basic principles for ECG interpretation Before you look at the ECG: Indication - 20 YO man with syncope - 50 YO man with acute chest pain - 65 YO woman with HTN and chronic SOB - 70 YO man with ESRD medications include digoxin, coming with altered level of consciousness - Muscle thickness, QT, arrhythmia - Chamber size and its complications - ischemia and its complications - electrolytes, drug toxicity Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Basic principles for ECG interpretation Screen the ECG for quality: Verify patients name, MRN, and date Make sure that voltage is 10 mm/mv and calibrated Screen for quality, correct lead placement, noise Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Nothing is Random in Life Na, TCA Nothing is Random in Life K Disturbance Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015. Ca Disturbance, Digoxin

Basic principles for ECG interpretation Know how to calculate the HR, PR, QRS, and QT Know what is a normal sinus morphology and identify abnormal Know what is normal axis, normal voltage, normal vs pathologic Q, juvenile patterns, normal variants Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Nomenclature Waves -P wave -T wave -U wave Complex -QRS Segments -PR segment -ST segment Intervals -PR interval -QT interval Point -J point 1 “little box” = 0.04 seconds (or 40 msec) 1 “big box” = 0.2 seconds (or 200 msec) 5 “little boxes” = 1 “big box” 5 “big boxes” = 1 second Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Step 1: Step 2: Locate RR interval: HR Rhythm & its origin Can be difficult and complex Most common mistake made by computer interpretation

For Boards Usually, your indication is your guide Expected not to miss a serious/deadly finding/diagnosis ST elevation Hyperkalemia Drug toxicity Major pathology: heart block, arrhythmia, HCM…………………….. Usually, your indication is your guide Do not worry about controversial or minor findings Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

ECG Coding Sheet: Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Inverted lead I in absence of Dextrocardia Abnormally, normal avR Unexpectedly "normal" Inverted lead I in absence of Dextrocardia Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Rhythm Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

So Far: You learned to ask about/present the indication before interpretation Scan for quality and lead placement Know the various electrical waves/intervals and what is normal ECG Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Chamber Abnormality Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

24 year old man with syncope Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

45 year old man with HTN Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

LVH Criteria: The Cornell criteria: Sokolow: R wave in aVL + S wave in V3 > 28 mm in males and > 20 mm in females of the voltage criteria. Therefore, the best policy is know most or all of the Sokolow: S in V1 or 2+ R in V5 or V6 > 35 mV R avL > 11 mV ST and/or T wave abnormalities, “strain” pattern Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

37 Right axis deviation (> +100 msec) Codes: 07 Sinus rhythm 37 Right axis deviation (> +100 msec) 41 Right ventricular hypertrophy 43 RBBB, complete 67 ST and/or T wave abnormalities secondary to hypertrophy Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Chest pain/SOB Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

46 Left posterior fascicular block Codes: 10 Sinus tachycardia 43 RBBB, complete 46 Left posterior fascicular block 53 Anterior or anteroseptal Q wave MI (age recent or acute) 57 Inferior Q wave MI (age recent or acute) 65 ST and/or T wave abnormalities suggesting myocardial injury Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Q1 Significant ST segment elevation consistent with myocardial injury or infarction is defined by: ≥ 1 mm STE in leads V1, V2, or V3 ≥ 2 mm STE in leads V1, V2, or V3 ≥ 2 in other leads ≥ 1 in other leads Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Q1 Significant ST segment elevation consistent with myocardial injury or infarction is defined by: ≥ 1 mm STE in leads V1, V2, or V3 ≥ 2 mm STE in leads V1, V2, or V3 ≥ 2 in other leads ≥ 1 in other leads Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Q2 Repolarization abnormality that suggest Acute or recent Myocardial infarction include: Peaked T waves followed by T wave inversion ST elevation followed by peaked T waves Deeply inverted T waves Dominant R wave and ST depression in V1-V3 Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Q2 Repolarization abnormality that suggest Acute or recent Myocardial infarction include: Peaked T waves followed by T wave inversion ST elevation followed by peaked T waves Deeply inverted T waves Dominant R wave and ST depression in V1-V3 Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Q3 Which parameter obtained on initial ECG independently predict 30 day all- cause mortality in acute myocardial infarction: Sinus tachycardia Sum of absolute ST segment deviation elevation and or depression QRS duration > 100 msec Rightward axis deviation Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Q3 Which parameter obtained on initial ECG independently predict 30 day all- cause mortality in acute myocardial infarction: Sinus tachycardia Sum of absolute ST segment deviation elevation and or depression QRS duration > 100 msec Rightward axis deviation Hathaway WR, et al. JAMA 1996, 273: 387-391. Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

06 Left atrial abnormality/enlargement 10 Sinus tachycardia Codes: 06 Left atrial abnormality/enlargement 10 Sinus tachycardia 36 Left axis deviation (> –30o) 47 LBBB, complete Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Q1 A QRS duration ≥ seconds is necessary for the diagnosis of complete LBBB: 0.10 0.11 0.12 0.13 Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Q1 A QRS duration ≥ seconds is necessary for the diagnosis of complete LBBB: 0.10 0.11 0.12 0.13 When LBBB morphology is present and the QRS duration measures > 0.10 seconds but < 0.12 seconds, incomplete LBBB should be coded. Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

LBBB is commonly seen in normal hearts: Q2 LBBB is commonly seen in normal hearts: True False Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

LBBB is commonly seen in normal hearts: Q2 LBBB is commonly seen in normal hearts: True False Never normal finding LBBB often occurs in various forms of organic heart disease, including ischemic and non-ischemic cardiomyopathy, valvular heart disease, LVH, and congenital heart disease. It is rarely seen in normal hearts Should not call it STEMI Should not call LVH: 80% patients with LBBB have abnormally increased LV mass Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Q3 Non-voltage related changes often associated with left ventricular hypertrophy include all the following except: Left atrial enlargement/abnormality Left axis deviation Intraventricular conduction disturbance Prominent U waves Sinus arrhythmia

Q3 Non-voltage related changes often associated with left ventricular hypertrophy include all the following except: Left atrial enlargement/abnormality Left axis deviation Intraventricular conduction disturbance Prominent U waves Sinus arrhythmia Non-voltage ECG changes in LVH LA abnormality/enlargement, left axis, IVCD, QRS prolongation, abnormal Q waves in leads III and aVF, prominent U waves, and repolarization abnormalities. Sinus arrhythmia (longest and shortest PP intervals vary by > 0.16 seconds or 10%) is a common finding on normal ECG’s that tends to occur in younger and healthier individuals and is not associated with LVH

LBBB interferes with the ECG diagnosis of: Q4 LBBB interferes with the ECG diagnosis of: QRS axis Left ventricular hypertrophy Right ventricular hypertrophy Acute MI

LBBB interferes with the ECG diagnosis of: Q4 LBBB interferes with the ECG diagnosis of: QRS axis Left ventricular hypertrophy Right ventricular hypertrophy Acute MI Formal diagnosis of LVH should not be made in the setting LBBB Echocardiographic and pathological studies show that ~ 80% patients with LBBB have abnormally increased LV mass

Bradycardia: A very big book in ECG Just on fun example

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

13 Atrial premature complexes Codes: 07 Sinus rhythm 13 Atrial premature complexes Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Tachycardia:

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Codes: Sinus tachycardia Paroxysmal SVT Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Killer Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

24 year old man with stressful life Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Electrolyte/Drug toxicity: Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

65 year old man ESRD on dialysis presented with acute confusion Peaked T waves Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

17 year old female found by her room mate unconscious Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.