![Page 1: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/1.jpg)
Dr Patrick KayInterventional Cardiologist
Middlemore and Mercy Hospitals
Auckland
16:30 - 17:25 WS #168: Update on ECGs
17:35 - 18:30 WS #180: Update on ECGs (Repeated)
![Page 2: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/2.jpg)
ECG Workshop
Patrick Kay MD PhD
Interventional and General Cardiologist
Auckland
![Page 3: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/3.jpg)
The ECG
• The normal ECG
• The ECG in ischaemia
• The bradycardias
• The tachycardias
• Miscellaneous
![Page 4: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/4.jpg)
The normal ECG
Rate
Rhythm
Axis
AVf positive
Lead I positive
Axis normal
AVf positive
Lead I negative
Right axis deviation
AVf negative
Lead I positive
Look at II if negative
Left axis deviation
AVf negative
Lead I negative
Axis North west
![Page 5: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/5.jpg)
The tachycardias - HR > 100
Broad complex Narrow complex
RegularRegular IrregularIrregular
Assume VT AF with
abherrancy
Sinus tachy
AVRT
AVNRT
Atrial tachycardia
Atrial flutter
Atrial
fibrillation
![Page 6: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/6.jpg)
Scenario
• 66 yr old female air travel AK-CHCH one week ago.
Dyslipidemic. Hypertensive.
• Car – CHCH-DN then back to Picton
• Flew from Nelson to AK
• Admitted with chest pain, SOB and small troponin rise.
![Page 7: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/7.jpg)
![Page 8: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/8.jpg)
![Page 9: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/9.jpg)
![Page 10: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/10.jpg)
![Page 11: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/11.jpg)
![Page 12: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/12.jpg)
What are these objects ?
![Page 13: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/13.jpg)
Scenario
• 38 G5P3
• Caesar – 3 litre blood loss – resus
20 mins later…3 litre blood loss
• Blood/products given. CVP=20.
• BP = 60/-
• Adrenaline, noradrenaline, milrinone, vasopressin
• “the more adrenaline I give the worse she gets….’
![Page 14: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/14.jpg)
![Page 15: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/15.jpg)
Normal
![Page 16: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/16.jpg)
NormalOur Patient
![Page 17: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/17.jpg)
Management
1.
2. Do urgent angiogram
3. ECMO
4. Continue to support. It will all be better in the morning.
![Page 18: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/18.jpg)
Scenario
• 48 yr male
• Dyslipidemic, Hypertensive, Proteinuric 4+
• CVA 2 years ago. Full recovery.
• Presents SOB, CP, Palpitations
• Troponin positive
• Angiogram normal
![Page 19: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/19.jpg)
![Page 20: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/20.jpg)
![Page 21: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/21.jpg)
Ischaemic heart disease
• Acute coronary syndromes
– Chest pain suggestive of myocardial
ischaemic
– ECG changes suggestive of ischaemia
– ST depression / ST elevation / T wave
changes
– Rise and fall in cardiac biomarker above
preset diagnsotic level
![Page 22: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/22.jpg)
Coronaries and limb leads
• LAD– Anteroseptal: V1-V4
– Anterolateral : V4,5,6,IAVL
– High Lateral: I, aVL
• RCA – Inferior: II, III, aVf
– Look at vR4
– If large dominant RCA with big postero-lateral: II, III, aVf and
– V4-V6
• Circumflex– V4-V6, I,aVL
– If large and dominant: V4-V6, I,aVL PLUS II, III and aVF
v1 v2
v4
v3
v5,6
aVLaVr
aVfIII II
II
![Page 23: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/23.jpg)
ST elevation
• >2 mm ST elevation in 2 contiguous leads in
v2-v5
• ≥1mm ST elevation in 2 contiguous limb
leads or true apical leads – v5 / 6
![Page 24: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/24.jpg)
T wave inversion-why?
![Page 25: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/25.jpg)
ST depression
>0.5mm ST depression is significant in 2 adjacent leads
![Page 26: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/26.jpg)
MI
![Page 27: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/27.jpg)
MI
![Page 28: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/28.jpg)
Is this an MI?
![Page 29: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/29.jpg)
Treatment
• ST elevation
– Aspirin, Ticagrelor/Clopidogrel, primary PCI or
fibrinolysis/delayed secondary PCI
• Non ST elevation
– Aspirin, Ticagrelor/Clopidogrel, low molecular weight heparin,
PCI / CABG, statin. Angiography < 48 hours.
![Page 30: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/30.jpg)
The Heart’s Conducting System
- The Bundles
Sinus node
AV node
His Purkinje
fibres
Left bundle
Right bundleAnterior
fasicle
Posterior
fasicle
![Page 31: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/31.jpg)
Left Bundle Branch Block
Ischaemic heart disease
Hypertension
Fibrotic degeneration
Aortic stenosis
Congestive / hypertrophic cardiomyopathy
Post CABG
![Page 32: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/32.jpg)
Partial RBBB
![Page 33: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/33.jpg)
Right Bundle Branch Block
As per LBBB and
May be normal finding
Pulmonary disease
Congenital heart disease
![Page 34: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/34.jpg)
Bifascicular Block
Left anterior hemiblock
Right Bundle Branch Block
![Page 35: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/35.jpg)
The Bradycardias (HR < 60)
• Is there AV association?
– If no then either Mobitz II or CHB / high vagal tone with junctional escape rate > sinus rate
• Is the PR interval normal?
• Cause
– High vagal tone / physiological, drugs, conducting tissue fibrosis / calcification, ischaemia, infection, infiltration, electrolytes , metabolic disease
![Page 36: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/36.jpg)
Sinus Bradycardia
![Page 37: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/37.jpg)
Junctional Bradycardia
![Page 38: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/38.jpg)
1st Degree AV Block
![Page 39: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/39.jpg)
Wenckebach (Mobitz I)
Maybe physiological / pathological – arises high in
conducting tissues – usually does not need Rx
![Page 40: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/40.jpg)
Mobitz II AV block
![Page 41: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/41.jpg)
3rd Degree AVB – Complete Heart Block
Narrow QRS – more stable higher escape
Broad QRS – low escape – more unstable
![Page 42: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/42.jpg)
AF and CHB
![Page 43: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/43.jpg)
The tachycardias - HR > 100
Broad complex Narrow complex
RegularRegular IrregularIrregular
Assume VT AF with
abherrancy
Sinus tachy
AVRT
AVNRT
Atrial tachycardia
Atrial flutter
Atrial
fibrillation
![Page 44: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/44.jpg)
Sinus tachycardia
![Page 45: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/45.jpg)
Atrial fibrillation
![Page 46: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/46.jpg)
Atrial flutter
![Page 47: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/47.jpg)
Treatment
• Anticoagulate – Pradaxa vs warfarin
• Rate vs rhythm control
• Curative – ablation/PVI
– Atrial flutter – >80% cured – may still get AF
– Atrial fibrillation – >70% first attempt; high 80% 3rd attempt at
PVI
![Page 48: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/48.jpg)
Thromboembolic complicationsRisk stratify-CHADSVASC
![Page 49: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/49.jpg)
Anti-Arrythmics
![Page 50: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/50.jpg)
Structurally normal
heart, No IHD
Structurally normal
heart , IHD
Structurally abnormal
heart, IHD
Structurally Abnormal Heart
• LV hypertrophy - >14mm
• LV dysfunction (LVEF <45%)
• Moderate or more valve disease
FlecainideSotalol
Amiodarone
![Page 51: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/51.jpg)
Paroxysmal SVT (AVNRT)
![Page 52: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/52.jpg)
Ventricular Ectopics / Bigemini
Left bundle – RV origin – LBBB / RAD : RV outflow tract
Right Bundle – LV origin – RBBB / LAD : LV outflow origin
![Page 53: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/53.jpg)
RVOT ectopy
availabledatadonotallowforaccurateriskprediction.A recent
longitudinalstudyfollowed239patientswith frequent PVCs(.1000perday)andnoSHD[echoand
magneticresonanceimaging(MRI)]for5.6yearswithno adverse
cardiaceventsandnodeclineinoverallLV ejection fraction(LVEF).32
![Page 54: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/54.jpg)
Premature ventricular complex-induced
cardiomyopathy • Several studies have demonstrated an association between frequent PVCs and a potentially reversible
cardiomyopathy, which in selected patients resolves after catheter ablation. The number of PVCs/24h that is
associated with impaired LV function has generally been reported at burdens above15 – 25% of the total cardiac
beats,though this may be as low as10%
• However,since PVCs may be the result of an underlying cardiomyopathy, it may be difficult to prospectively
determine which of these sequences is operative in a given patient.
• Importantly, the vast majority of patients with frequent PVCs will not go onto develop cardiomyopathy but currently
available data do not allow for accurate risk prediction.
• A recent longitudinal study followed 239 patients with frequent PVCs(.1000 per day)and no SHD[echo and magnetic
resonance imaging(MRI)]for5.6years with no adverse cardiac events and no decline in overall lLV ejection
fraction(LVEF).
![Page 55: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/55.jpg)
Features suggestive of VT
• AV dissociation
• Positive concordance
• Fusion beats – supraventricular beats getting through
• Capture beats – VT starting
• Wayward axis
• Very broad complex (>140msec)
• Same morphology as VEs / change from SR
• Previous MI
![Page 56: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/56.jpg)
Monomorphic VT
AV dissociation
Morphology LBBB vs RBBB
Axis
Cycle length
![Page 57: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/57.jpg)
ARVD
Right axis
deviation
Epsilon wave
T wave inversion
![Page 58: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/58.jpg)
Polymorphic VT
Torsades de Pointes – polymorphic VT associated
with long QT interval
Congenital / Acquired – drugs, electrolytes
![Page 59: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/59.jpg)
Long QT Syndrome
QTc = QT measured
preceding R-R interval
![Page 60: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/60.jpg)
Ventricular Fibrillation
Electricity
![Page 61: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/61.jpg)
Treatment of ventricular arrhythmias
Haemodynamically
stable
Electricity
NO
Drugs
- amiodaroneYes
Address underlying
cause
•Ischaemia – reperfuse / revascularise
•Electrolytes
•Drugs
•Assess LV function –
bad ?ICD, good:
drugs /? ICD
![Page 62: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/62.jpg)
Cheick Ismaël Tioté
![Page 63: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/63.jpg)
Cause of Sudden Death in Young People
• Hypertrophic obstructive cardiomyopathy (HOCM).
• Dilated cardiomyopathy.
• Arrhythmogenic right ventricular cardiomyopathy (ARVC).
• Cardiac ion channelopathies - eg, congenital long QT syndrome (LQTS), Brugada's syndrome, short QT syndrome.
• Catecholaminergic polymorphic ventricular tachycardia (CPVT).
• Valvular heart disease (with or without infective endocarditis) - eg, aortic stenosis, mitral valve prolapse.
• Cyanotic heart disease - eg, Fallot's tetralogy, transposition.
• Acyanotic heart disease - eg, ventricular septal defect, patent ductus arteriosus.
• Cardiac arrhythmias - eg, Wolff-Parkinson-White syndrome.
• Coronary heart disease: acute myocardial infarction, congenital anomaly of coronary arteries, coronary artery
embolism, coronary arteritis.
• Myocarditis.
• Myotonic dystrophy.
• Kawasaki disease.
• Commotio cordis (traumatic blow to the chest wall).
![Page 64: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/64.jpg)
Figure 1
The American Journal of Medicine 2016 129, 1170-1177DOI: (10.1016/j.amjmed.2016.02.031)
Copyright © 2016 Elsevier Inc. Terms and Conditions
![Page 65: Dr Patrick Kay - GP CME North/Sat_Room4_1630_Kay_The ECG... · 2017. 6. 10. · Scenario • 38 G5P3 • Caesar –3 litre blood loss –resus 20 mins later…3 litre blood loss •](https://reader036.vdocuments.us/reader036/viewer/2022071111/5fe7299f56c5a5332d2b94ab/html5/thumbnails/65.jpg)
Figure 2
The American Journal of Medicine 2016 129, 1170-1177DOI: (10.1016/j.amjmed.2016.02.031)
Copyright © 2016 Elsevier Inc. Terms and Conditions