1. INTERPRETATION of ELECTROCARDIOGRAMS BRIAN D. LE, MD Presbyterian Hospital CIVA

2. Outline I. Approach to interpretation of ECGs II. Cases illustrating approach principles III. Unusual Cases

5. Seven Step Approach Rate Rate Rhythm Rhythm Axis Axis Intervals Intervals Hypertrophy Hypertrophy ST/Tw changes, Q waves ST/Tw changes, Q waves Conduction system Conduction system

6. Seven Step Approach Rate Rate Rhythm Rhythm Axis Axis Intervals Intervals Hypertrophy Hypertrophy ST/Tw changes, Q waves ST/Tw changes, Q waves Conduction system Conduction system

8. Seven Step Approach Rate Rate Rhythm Rhythm Axis Axis Intervals Intervals Hypertrophy Hypertrophy ST/Tw changes, Q waves ST/Tw changes, Q waves Conduction system Conduction system

11. Seven Step Approach Rate Rate Rhythm Rhythm Axis Axis Intervals Intervals Hypertrophy Hypertrophy ST/Tw changes, Q waves ST/Tw changes, Q waves Conduction system Conduction system

14. Seven Step Approach Rate Rate Rhythm Rhythm Axis Axis Intervals Intervals Hypertrophy Hypertrophy ST/Tw changes, Q waves ST/Tw changes, Q waves Conduction system Conduction system

15. INTERVALS PR < 200 ms QRS < 120 ms QTc: Men < 440 ms, Women < 460 ms

16. Seven Step Approach Rate Rate Rhythm Rhythm Axis Axis Intervals Intervals Hypertrophy Hypertrophy ST/Tw changes, Q waves ST/Tw changes, Q waves Conduction system Conduction system

17. Left Ventricular Hypertrophy Left Ventricular Hypertrophy Cornell +R (aVL)+Sw(V3)>24mm (male) >20mm (female) Cornell +R (aVL)+Sw(V3)>24mm (male) >20mm (female) Sokolow S(V1) + R(V5)=32mm Sokolow S(V1) + R(V5)=32mm Rw (aVL)>11mm Rw (aVL)>11mm Rw (I)>14mm Rw (I)>14mm

18. Right Ventricular Hypertrophy Right Ventricular Hypertrophy 1. RAD>100* 1. RAD>100* 2. IRBBB 2. IRBBB 3. R>S V1 3. R>S V1 4. R<S V6 4. R<S V6 5. R in V1>=7mm 5. R in V1>=7mm 6. R V1 + S V5 or V6 >=10mm 6. R V1 + S V5 or V6 >=10mm 7. RAE 7. RAE 8. strain pattern in rt precordial leads 8. strain pattern in rt precordial leads

19. Seven Step Approach Rate Rate Rhythm Rhythm Axis Axis Intervals Intervals Hypertrophy Hypertrophy ST/Tw changes, Q waves ST/Tw changes, Q waves Conduction system Conduction system

20. ANATOMICAL LOCALIZATION ANTERIOR: V1-V4, SEPTAL V1-V2 LATERAL: V5-V6, I, Avl INFERIOR: II, III, aVF

21. Seven Step Approach Rate Rate Rhythm Rhythm Axis Axis Intervals Intervals Hypertrophy Hypertrophy ST/Tw changes, Q waves ST/Tw changes, Q waves Conduction system Conduction system

24. LBBB LBBB QRS > 0.12 sec QRS > 0.12 sec wide monophasic R in I, V5 and V6 wide monophasic R in I, V5 and V6 (usually notched or slurred) (usually notched or slurred) no Q in I, V5 and V6 no Q in I, V5 and V6 Left Anterior Fascicular Block Left Anterior Fascicular Block LAD > -30', + I, aVR, -II/III/aVF LAD > -30', + I, aVR, -II/III/aVF qR in I and L qR in I and L rS in II, III and aVF rS in II, III and aVF Left Posterior Fascicular Block Left Posterior Fascicular Block RAD > 100' RAD > 100' small R in I and aVL, Q in II, III, aVF small R in I and aVL, Q in II, III, aVF S1 Q3 pattern S1 Q3 pattern RBBB RBBB QRS>0.12 sec QRS>0.12 sec R' > r in right precordium R' > r in right precordium wide S in I, V5 and V6 wide S in I, V5 and V6

25. Normal Variants- Juvenile Tw inversions

26. Nuts and Bolts

27. Electrode Misplacement

28. Amplitude Artifact

29. Parkinson’s Tremor

30. CASES

31. Case 1: 21 yo presents for routine physical exam

32. DEXTROCARDIA

33. Case 2: 38 yo with one week of URI presents with chest pain

34. Acute Pericarditis Stage I--ST elevation, Tw upright, Stage I--ST elevation, Tw upright, PR depression PR depression Stage II--ST baseline, flattened Tw Stage II--ST baseline, flattened Tw Stage III--inv Tw Stage III--inv Tw Stage IV--Tw baseline, days to wks Stage IV--Tw baseline, days to wks

35. Case 3: 48 yo homeless man found unresponsive

36. Hypothermia

37. Case 4: 34 yo ESRD missed three days of dialysis

38. Hyperkalemia

39. Case 5: 28 yo woman s/p neck surgery

40. Hypocalcemia

41. Case 6: 32 yo female on antidepressants had syncope

42. Acquired Long QT Syndrome

43. Case 7: 60 yo man with chest pain

44. Inferior MI with RV infarction and 2:1 and complete heart block

45. 2:1 Heart block with ventriculophasic effect

47. Case 8 : 80 yo man with syncope

48. Aflutter with complete heart block Aflutter with normal conduction Aflutter with complete heart block

49. Aflutter with 1:1 conduction

50. Aflutter with carotid sinus massage

51. Counter-clockwise Aflutter

52. Clockwise Aflutter

53. Case 9: 50 yo man with DCM

54. Biventricular pacing

57. Case 10 : 25 yo man with palpitations

58. Pre-excited Atrial Fibrillation- right sided postero-septal pathway

59. Wolf-Parkinson-White: Left anterolateral pathway

60. Postero-septal pathway pre-ablation

61. Post-ablation with repolarization abn due to memory effect

62. Case 11: 25 yo female with lightheadedness

63. AV Node Re-entrant Tachycardia (AVNRT)

64. Case 12: 75 yo man with ischemic DCM and syncope

65. Ventricular Tachycardia BRUGADA'S CRITERIA- Circulation '91 BRUGADA'S CRITERIA- Circulation '91 1. Absence of all RS complex in all precordial leads S 21%, SP 100% 1. Absence of all RS complex in all precordial leads S 21%, SP 100% 2. R to S interval > 100ms in one precordial lead S 65%, SP 98% 2. R to S interval > 100ms in one precordial lead S 65%, SP 98% 3 A-V Dissociation, fusion, capture beats S 82%, SP 98% 3 A-V Dissociation, fusion, capture beats S 82%, SP 98% 4. Morphologic criteria in V1+2, 6 4. Morphologic criteria in V1+2, 6

66. Ventricular Tachycardia

67. Ventricular Tachycardia: AV dissociation, RS >100ms

68. Case 13: 18 yo Asian man with family history of SCD presents with syncope

69. Brugada Syndrome Genetic mutation in SCNA5 Genetic mutation in SCNA5 Predominantly in Asian males Predominantly in Asian males Syncope and sudden cardiac death Syncope and sudden cardiac death Three types Three types

70. Brugada’s Type II- Saddle back

71. Case 14: 28 yo man with syncope

72. Arrythmogenic Right Ventricular Dysplasia (ARVD)

73. Case 15: 28 yo man with syncope

74. Short-coupled Torsades

75. Case 16 : 34 yo woman with fatigue, weight gain, and abn menstrual period

76. Myxedema

77. Case 17: 84 yo man with skipped beats

78. Sino-atrial exit block Type I

79. Case 18 : 64 yo woman presents for routine exam

80. Retrograde concealed conduction into the AV node