cardiology/ekg board review · pdf filecardiology/ekg board review michael j. bradley d.o....

Cardiology/EKGBoardReviewMichaelJ.BradleyD.O.DME/ProgramDirector

FamilyMedicineResidency

ObjecCves

•  ReviewgeneralmethodforEKGinterpretaCon•  Reviewspecificpointsof“datagathering”and“diagnoses”onEKG

•  ReviewtreatmentconsideraCons•  Reviewclinicalcases/EKG’s•  BoardexamconsideraCons

EKG–12Leads

•  AnteriorLeads-V1,V2,V3,V4•  InferiorLeads–II,III,aVF•  LeVLateralLeads–I,aVL,V5,V6•  RightLeads–aVR,V1

11StepMethodforReadingEKG’s

•  “DataGathering”–steps1-4– 1.StandardizaCon–makesurepaperandpaperspeedisstandardized

– 2.HeartRate– 3.Intervals–PR,QT,QRSwidth– 4.Axis–normalvs.deviaCon

11StepMethodforReadingEKG’s

•  “Diagnoses”–  5.Rhythm–  6.Atrioventricular(AV)BlockDisturbances–  7.BundleBranchBlockorHemiblock of–  8.PreexcitaCon ConducCon–  9.EnlargementandHypertrophy–  10.CoronaryArteryDisease–  11.UgerConfusion

•  TheOnlyEKGBookYou’llEverNeedMalcolmS.Thaler,MD

HeartRate

•  RegularRhythms

HeartRate

•  IrregularRhythms

Intervals

•  MeasurelengthofPRinterval,QTinterval,widthofPwave,QRScomplex

QTc

•  QTc=QTintervalcorrectedforheartrate– UsesBazeg’sFormulaorFridericia’sFormula

•  LongQTsyndrome–inheritedoracquired(>75meds);torsadesdeponites/VF;syncope,seizures,suddendeath

Rhythm

•  4QuesCons– 1.ArenormalPwavespresent?– 2.AreQRScomplexesnarroworwide(≤or≥0.12)?– 3.WhatisrelaConshipbetweenPwavesandQRS

complexes?– 4.Isrhythmregularorirregular?

•  Sinusrhythm=normalPwaves,narrowQRScomplexes,1Pwavetoevery1QRScomplex,andregularrhythm

TypesofArrhythmias

•  Arrhythmiasofsinusorigin•  Ectopicrhythms•  ConducConBlocks•  PreexcitaConsyndromes

AVBlock•  DiagnosedbyexaminingrelaConshipofPwavestoQRS

complexes•  FirstDegree–PRinterval>0.2seconds;allbeats

conductedthroughtotheventricles•  SecondDegree–onlysomebeatsareconductedthrough

totheventricles–  MobitzTypeI(Wenckebach)–progressiveprolongaConofPR

intervalunClaQRSisdropped–  MobitzTypeII–All-or-nothingconducConinwhichQRS

complexesaredroppedwithoutPRintervalprolongaCon•  ThirdDegree–Nobeatsareconductedthroughtothe

ventricles;completeheartblockwithAVdissociaCon;atriaandventriclesaredrivenbyindividualpacemakers

BundleBranchBlocks

•  DiagnosedbylookingatwidthandconfiguraConofQRScomplexes

BundleBranchBlocks

•  RBBBcriteria:–  1.QRScomplex>0.12seconds–  2.RSR’inleadsV1andV2(rabbitears)withSTsegmentdepression

andTwaveinversion–  3.ReciprocalchangesinleadsV5,V6,I,andaVL

•  LBBBcriteria:–  1.QRScomplex>0.12seconds–  2.BroadornotchedRwavewithprolongedupstrokeinleadsV5,V6,I,

andaVLwithSTsegmentdepressionandTwaveinversion.–  3.ReciprocalchangesinleadsV1andV2.–  4.LeVaxisdeviaConmaybepresent.

BundleBranchBlocks

Hemiblocks

•  DiagnosedbylookingatrightorleVaxisdeviaCon

•  LeVAnteriorHemiblock–  1.NormalQRSduraConandnoSTsegmentorTwavechanges–  2.LeVaxisdeviaCongreaterthan-30°–  3.NoothercauseofleVaxisdeviaConispresent

•  LeVPosteriorHemiblock–  1.NormalQRSduraConandnoSTsegmentorTwavechanges–  2.RightaxisdeviaCon–  3.NoothercauseofrightaxisdeviaConispresent

BifascicularBlock

•  RBBBwithLAH– RBBB–QRS>0.12secandRSR’inV1andV2withLAH–leVaxisdeviaCon

•  RBBBwithLPH– RBBB–RS>0.12secandRSR’inV1andV2withLPH–rightaxisdeviaCon

PreexcitaCon•  Wolff-Parkinson-White(WPW)Syndrome

–  1.PRinterval<0.12sec–  2.WideQRScomplexes–  3.Deltawavesseeninsomeleads

•  Lown-Ganong-Levine(LGL)Syndrome––  1.PRinterval<0.12sec–  2.NormalQRSwidth–  3.Nodeltawave

•  CommonArrhythmias–  ParoxysmalSupraventricularTachycardia(PSVT)–narrowQRS’s

aremorecommonthanwideQRS’s–  AtrialFibrillaCon–canberapidandleadtoventricular

fibrillaCon

PreexcitaCon

WPW LGL

SupraventricularArrhythmias•  PSVT-regular;Pwavesretrogradeifvisible;rate150-250bpm;

caroCdmassage:slowsorterminates•  Fluger–regular;saw-toothedpagern;2:1,3:1,4:1,etc.block;

atrialrate250-350bpm;ventricularrate½,⅓,¼,etc.ofatrialrate;caroCdmassage:increasesblock

•  FibrillaCon–irregular;undulaCngbaseline;atrialrate350to500bpm;variableventricularrate;caroCdmassage:mayslowventricularrate

•  MulCfocalatrialtachycardia(MAT)–irregular;atleast3differentPwavemorphologies;rate–usually100to200bpm;someCmes<100bpm;caroCdmassage:noeffect

•  PAT–regular;100to200bpm;characterisCcwarm-upperiodintheautomaCcform;caroCdmassage:noeffect,ormildslowing

SupraventricularArrhythmias

RulesofAberrancyVentricularTachycardia Paroxysmal

supraventricularTachycardia

ClinicalCluesClinicalHistory Diseasedheart Usuallynormalheart

CaroCdMassage Noresponse Mayterminate

CannonAWaves Maybepresent Notseen

EKGCluesAVDissociaCon Maybeseen Notseen

Regularity Slightlyirregular Veryregular

FusionBeats Maybeseen Notseen

IniCalQRSdeflecCon MaydifferfromnormalQRScomplex

SameasnormalQRScomplex

VentricularArrhythmias

TorsadesdePointes

PVC’s

AtrialEnlargement•  LookatPwavesinleadsIIandV1•  Rightatrialenlargement(Ppulmonale)–  1.IncreasedamplitudeinfirstporConofPwave–  2.NochangeinduraConofPwave–  3.PossiblerightaxisdeviaConofPwave

•  LeVatrialenlargement(pmitrale)–  1.Occasionally,increasedamplitudeofterminalpartofPwave

–  2.Moreconsistently,increasedPwaveduraCon–  3.NosignificantaxisdeviaCon

VentricularHypertrophy•  LookattheQRScomplexesinallleads•  Rightventricularhypertrophy(RVH)

–  1.RAD>100°–  2.RaCoofRwaveamplitudetoSwaveamplitude>1inV1and<1inV6

•  LeVventricularhypertrophy(LVH)

PrecordialCriteria LimbLeadCriteriaRwaveinV5orV6+SwaveinV1orV2>35mm

RwaveinaVL>13mm

RwaveinV5>26mm RwaveinaVF>21mm

RwaveinV6>18mm RwaveinI>14mm

RwaveinV6>RwaveinV5

RwaveinI+SwaveinIII>25mm

MyocardialInfarcCon

•  Dx–Hx,PE,serialcardiacenzymes,serialEKG’s

•  3EKGstagesofacuteMI– 1.Twavepeaksandtheninverts– 2.STsegmentelevates– 3.Qwavesappear

QWaves

•  CriteriaforsignificantQwaves– Qwave>0.04secondsinduraCon– Qwavedepth>⅓heightofRwaveinsameQRScomplex

•  CriteriaforNon-QWaveMI– Twaveinversion– STsegmentdepressionpersisCng>48hoursinappropriateclinicalse{ng

LocalizingMIonEKG•  InferiorinfarcCon–leadsII,III,aVF

–  OVencausedbyocclusionofrightcoronaryarteryoritsdescendingbranch

–  ReciprocalchangesinanteriorandleVlateralleads•  LateralinfarcCon–leadsI,aVL,V5,V6

–  OVencausedbyocclusionofleVcircumflexartery–  Reciprocalchangesininferiorleads

•  AnteriorinfarcCon–anyoftheprecordialleads(V1-V6)–  OVencausedbyocclusionofleVanteriordescendingartery–  Reciprocalchangesininferiorleads

•  PosteriorinfarcCon–reciprocalchangesinleadV1(STsegmentdepression,tallRwave)–  OVencausedbyocclusionofrightcoronaryartery

LocalizingMIonEKG

STsegment•  ElevaCon– SeenwithevolvinginfarcCon,Prinzmetal’sangina– Othercauses–JpointelevaCon,apicalballooningsyndrome,acutepericardiCs,acutemyocardiCs,hyperkalemia,pulmonaryembolism,Brugadasyndrome,hypothermia

•  Depression– SeenwithtypicalexerConalangina,non-QwaveMI–  Indicatorof+stresstest

ElectrolyteAbnormaliCesonEKG

•  Hyperkalemia–peakedTwaves,prolongedPR,flagenedPwaves,widenedQRS,mergingQRSwithTwavesintosinewave,VF

•  Hypokalemia–STdepression,flagenedTwaves,Uwaves

•  Hypocalcemia–prolongedQTinterval•  Hypercalcemia–shortenedQTinterval

Drugs•  Digitalis–  TherapeuCclevels–STsegmentandTwavechangesinleadswithtallRwaves

–  Toxiclevels–tachyarrhythmiasandconducConblocks;PATwithblockismostcharacterisCc.

•  MulCpledrugsassociatedwithprolongedQTinterval,Uwaves–  Sotalol,quinidine,procainamide,disopyramide,amiodarone,dofeClide,dronedarone,TCA’s,erythromycin,quinolones,phenothiazines,variousanCfungals,someanChistamines,citalopram(onlyprolongedQTinterval–dose-dependent)

EKG∆’sinotherCardiacCondiCons•  PericardiCs–DiffuseSTsegmentelevaConsandTwaveinversions;largeeffusionmaycauselowvoltageandelectricalalternans(alteringQRSamplitudeoraxisandwanderingbaseline)

•  MyocardiCs–conducConblocks•  HypertrophicCardiomyopathy–ventricularhypertrophy,leVaxisdeviaCon,septalQwaves

EKG∆’sinPulmonaryDisorders

•  COPD–lowvoltage,rightaxisdeviaCon,andpoorRwaveprogression.

•  Chroniccorpulmonale–PpulmonalewithrightventricularhypertrophyandrepolarizaConabnormaliCes

•  Acutepulmonaryembolism–rightventricularhypertrophywithstrain,RBBB,andS1Q3T3(withTwaveinversion).SinustachycardiaandatrialfibrillaConarecommon.

EKG∆’sinOtherCondiCons•  Hypothermia–Osbornwaves,prolongedintervals,sinusbradycardia,slowatrialfibrillaCon,bewareofmuscletremorarCfact

•  CNSDisease–diffuseTwaveinversionwithTwaveswideanddeep,Uwaves

•  Athlete’sHeart–sinusbradycardia,nonspecificSTsegmentandTwavechanges,RVH,LVH,incompleteRBBB,firstdegreeorWenckebachAVblock,possiblesupraventriculararrhythmia

UgerConfusion

•  Verifyleadplacement•  RepeatEKG•  RepeatstandardizedprocessofEKGanalysis-starCngoverfromthebeginningwithbasics–rate,intervals,axis,rhythm,etc.andproceedthroughenCrestepwiseanalysis

•  ConsiderCardiologyconsultaCon

ArrhythmiaIndicaConstoConsultCardiology

•  DiagnosCcormanagementuncertainty•  MedicaConsnotcontrollingsymptoms•  PaCentisinhigh-riskoccupaConorparCcipatesinhigh-riskacCviCes(pilot,scubadriving)

•  PaCentsprefersintervenConoverlong-termmeds•  PreexcitaCon•  Underlyingstructuralheartdisease•  Associatedsyncopeorothersignificantsymptoms•  WideQRS

CareConsideraConsPriortoCardiologyConsult

•  ThoroughHxandPE•  Basiclabs•  EKGandrepeatEKG•  Holtermonitor•  Echocardiogram•  Acuityofcarerequired–considerrisks,hemodynamicstability

PacemakerConsideraCons

•  Third-degree(complete)AVblock•  SymptomaCclesserdegreeAVblockorbradycardia

•  SuddenonsetofvariouscombinaConsofAVblockandBBBduringacuteMI

•  Recurrenttachycardiasthatcanbeoverdrivenandterminatedbypacemakers

OsteopathicConsideraCons

•  Treatments–– LymphaCcs–thoracicinlet,abdominaldiaphragm,ribraising,lymphaCcpumps

– SympatheCcs(T1-T6)–cervicalganglion,ribraising,T1-T6,Chapman’sreflexes,T10-L2foradrenal/kidney

– ParasympatheCcs–OA/AA/cranial–vagusnerve

ClinicalCases/EKG’s

Case1•  53yearoldcaucasianfemalewith4dayhxofseverecentralchestpainonexerCon,previouslyalleviatedwithrest;nowworsenedoverlast24hoursandsustainedatrest

•  PMHx–DM2,HTN,hyperlipidemia•  Appearsunwell,inpain,sweaty,andgrey

Case1

•  Diagnosis?EKGfindings?

Case1

•  AcuteanteriorST-elevaConMIwith“tombstone”or“fireman’shat”inV1-V4

•  Tx?LocalizaCon?

Case1•  PCIstenCngofLAD

•  Post-procedure=resolvingSTelevaCon;lossofominoustombstoneeffect;Qwavesdeveloping

Case2

•  45yomalepresentswithacuteSOBs/plongvacaConinParis

•  PMHx-asthma,Crohn’sdisease,anxiety,GERD,tobaccoabuse

•  VS37,148/92,130,26•  PaCentappearsuncomfortablebutotherwiseunremarkableexam

Case2


Case2

•  AcutePEwithsinustachycardia,aPVC,andS1Q3T3pagern

Case3

•  72yomalepresentstotheofficeforevaluaConpriortocataractsurgery

•  Nocomplaints•  PMHx–B/Lcataracts,OA,HTN,hyperlipidemia,andchroniclowbackpain

•  VS37.2,152/86,74,14

Case3


Case3

•  LVH–QRSvoltagecriteriainprecordialleadsandrepolarizaConchangesinV5,V6

Case4

•  27yofemalepresentstotheEDwithc/ochestdiscomfortandpalpitaConsaVerstudyingallnightforgraduateschoolexams

•  Appearsnervousand“uneasy”withrapidpulse

•  PMHx–unremarkable;nomeds,admitstooccasionalalcohol,non-smoker,deniesillicitdruguse,usedcoffeetostayawaketostudy

Case4


Case4

•  SVT–regular,narrow-QRStachycardia,rateof160bpm

Case5

•  46yomalepresentstoEDwithc/osevereHApersisCngover5hoursdespiteacetaminophenandNSAIDagemptsasaborCvetherapy

•  PMHx–occasionalleVshoulderpain,non-smoker

•  ConstrucConworker•  VSS;unremarkableexam

Case5


Case5

•  NormalEKG

Case6

•  56yofemalepresentstofamilyphysicianwithc/olight-headednessandoccasionalflugerinherchest

•  PMHx–anxiety,depression,obesity,smoker•  Worksasretailstoremanager•  VSS;coursebreathsounds,otherwiseunremarkableexam

Case6


Case6

•  SeconddegreeAVblock–MobitzTypeI–Wenckebach(specifically3:2AVWenckebachphenomenonwhereevery3rdPwaveisblocked)

Case7

•  28yomalepresentsforcommercialdriver’slicense(CDL)evaluaCon

•  Nocomplaints•  VSS;asymptomaCc;examwithoutsignificantfindings

Case7


Case7

•  TypicalpreexcitaCon(WPW)pagern•  ShortPRintervalanddeltawavesinmanyleads

•  TxiscloseobservaConunlesspaCenthashadSVToratrialfibrillaConwhichindicatestxwithablaConofaccessorypathway

Case8

•  32yomalepresentstoEDwithc/ofeelingsickforthelast6days

•  Symptomsincludefevers,cough,anddifficultycatchinghisbreath

•  PMHx–hyperlipidemia,obesity,metabolicsyndrome

•  VS38.1,105,128/84,22

Case8


Case8

•  AcutepericardiCs–diffuseSTelevaConwithPRsegmentdepressionisdiagnosCc

Case9

•  67yomalepresentstohiscardiologistforout-paCent6weekpost-hospitalvisit

•  PrevioushospitalizaConfornon-cardiacchestpain

•  Post-hospitalcardiacmeds–ACEinhibitor,betablocker,aspirin,nitrate

•  Nocurrentcomplaints

Case9


Case9

•  AtrialfibrillaCon–irregularlyirregularwithoutPwaves

•  RBBB–wideQRSwithrsR’pagerninV1,broadSwavesinleadsIandaVL

•  Inferiorinfarct–non-acute(>1week)pathologicQwavesininferiorleads(II,III,andaVF)

Case10

•  79yomalebroughttoEDviaEMSwithchestpain,SOB,andnear-syncope

•  PMHx–unobtainablesecondarytopaCentdistress

•  VS–36.9,140’s,82/40,28

Case10


Case10

•  Monomorphicsustainedventriculartachycardia(VT)–couldrapidlydeteriorateintoVF,torsadesdepointes,asystole,orsuddendeath

Case11

•  82yofemaleadmigedtoacutecarehospitalsecondarytochestpain

•  PMHx–HTN,DM2,CHF,obesity,depression•  CardiologyplanningcardiaccatheterizaConsecondarytonewfindingduringiniCalconsultaCon

Case11


Case11

•  LBBB–wideQRS;broad,notchedRwaveinV5,V6andIwithSTdepressionandTwaveinversion

Case12

•  59yomalepresentstoEDdiaphoreCcandindistress

•  PMHx–HTN,ESRD,DM2,LeVBKA•  VS–37.5,108,96/58,24

Case12


Case12

•  Hyperkalemia–tallpeakedTwavespresentthroughout;otherprogressiveEKGchangesmayfollowwithincreasingpotassiumlevels–prolongedPRinterval,flagenedPwaves,wideningQRS,sinewaves

•  Sinustachycardiaalsopresent

BonusCase

•  18yomaleundergoingmilitaryphysicalexamandevaluaConpriortobootcamp

•  Nocomplaints•  PMHx–denies•  VSS;examunremarkable

BonusCase


BonusCase

•  Reversedarmleads–invertedPwavesinleadIwithnormalRwaveprogressioninprecordialleads

BoardExamPoints

•  EKG’slikelytohave1mainfinding•  ClinicalcaselikelyincludedwitheachEKG•  QuesConlikelytofocusonclinicalcaseaswellasEKG

•  Straightforwardwithouttricksorobscurefindings(notlikelytosee“zebras”)

•  Focusoncommonarrhythmias,commoncardiacdiagnoses,commonnon-cardiacEKGabnormaliCes,oremergent“can’tmiss”diagnoses

QuesCons?

Resources•  SourcesandSuggestedReferences

–  TheOnlyEKGBookYou’llEverNeed-MalcolmS.Thaler–  RapidInterpretaConofEKG’s–DaleDubin,M.D.–  “…ExceptforOMT!”–DalePrag-Harrington–  AmericanFamilyPhysician–November1,2015–  UptoDate–  blogatwordpress.com–  cme.umn.edu–  ekgcasestudies.com–  healio.com–  lifeinthefastlane.com–  learntheheart.com

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