pregnancy and the heart - acp
TRANSCRIPT
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Disclosures
• None
©2011 MFMER
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©2011 MFMER
Puerto Rico ACP Internal Medicine Update and Board Review
ECG Review
Fred Kusumoto MD Professor of Medicine
Mayo Clinic College of Medicine March 8,2019
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Clinical Use of the ECG
©2011 MFMER
Chest pain
Presence or
absence of
“structural heart
disease”
Ischemia
Other
Syncope
Palpitations
SOB/fatigue
“Orphans”
“Now that’s
Interesting”
Current
Arrhythmia
Bradycardia
Tachycardia
Palpitations
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Bernath and Kusumoto. ECG Interpretation for Everyone 2011
• Characteristic changes with myocardial injury
• “Fake-outs”
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Case #1: 46 year old policeman with “burning” in the chest when riding a bicycle
Kusumoto FM. Cardiovascular Pathophysiology Hayes Barton 1999
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Case #1 (continued): “Burning” has resolved
Kusumoto FM. Cardiovascular Pathophysiology Hayes Barton 1999
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Case #1 (continued): “Burning” has resolved
Kusumoto FM. Cardiovascular Pathophysiology Hayes Barton 1999
Dynamic ST/T changes with symptoms/resolution of symptoms are important
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Ischemia leads to “localized hyperkalemia”
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Case #2: 54 year old woman with 4 hours of chest pain presents in the ER
©2011 MFMER
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Regionalization/Localization of ST/T Changes (particularly ST segment elevation)
Kusumoto in McPhee Pathophysiology of Disease Lange 2013
Anterior Inferior
Lateral
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Bernath and Kusumoto. ECG Interpretation for Everyone 2011
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Bernath and Kusumoto. ECG Interpretation for Everyone 2011
III II aVF
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Bernath and Kusumoto. ECG Interpretation for Everyone 2011
III II aVF
aVL
I
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Case #2: 54 year old woman with 4 hours of chest pain presents in the ER
©2011 MFMER
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Case #2 (continued): Cardiac catheterization laboratory
©2011 MFMER
Kusumoto FM and Bernath P, ECG Interpretation: for Everyone 2011
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Case #2 (continued): Day #1
©2011 MFMER
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Case #2 (continued): Day #2
©2011 MFMER
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Bernath and Kusumoto. ECG Interpretation for Everyone 2011
• Dynamic Changes with symptoms
• Regionalization
• Reciprocal changes
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Kusumoto, ECG Interpretation: from Pathophysiology to Clinical Application 2009
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Kusumoto, ECG Interpretation: From Pathophysiology to Clinical Application 2009
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Kusumoto, ECG Interpretation: From Pathophysiology to Clinical Application 2009
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“T wave follows the QRS complex” Electrophysiologic mechanism
Epicardium
Endocardium
Repolarization
Depolarization
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“In conduction block, the T wave is opposite the QRS complex”
Epicardium
Endocardium
Repolarization
Depolarization
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Kusumoto, ECG Interpretation: From Pathophysiology to Clinical Application 2009
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Kusumoto, ECG Interpretation: From Pathophysiology to Clinical Application 2009
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ST segment elevation
• Characteristic changes with myocardial ischemia/injury
• Dynamic changes with Sx
• Localization to a specific region of the heart
• Always look for ST segment elevation first
• Reciprocal changes
• “Fake-outs”
©2011 MFMER
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ST segment elevation
• Characteristic changes with myocardial ischemia/injury
• Dynamic changes with Sx
• Localization to a specific region of the heart
• Always look for ST segment elevation first
• Reciprocal changes
• “Fake-outs”
©2011 MFMER
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Case #3: 73 year old woman with a prior MI but no chest pain
©2011 MFMER
Kusumoto, ECG Interpretation: From Pathophysiology to Clinical Application 2009
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Kusumoto, ECG Interpretation: From Pathophysiology to Clinical Application 2009
Pericarditis: 1. Diffuse ST elevation
2. PR segment depression
3. No Q waves
4. aVR: PR segment elevation & ST depression
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Kusumoto, ECG Interpretation: From Pathophysiology to Clinical Application 2009
Early repolarization: 1. Prominent T’s relative to the ST
2. No reciprocal changes
3. No Q waves
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Kusumoto, ECG Interpretation: From Pathophysiology to Clinical Application 2009
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Kusumoto, ECG Interpretation: From Pathophysiology to Clinical Application 2009
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Non-infarction causes of ST segment elevation
• Cardiac
• Bundles (Pacing), early repolarization
• Aneurysm
• Coronary artery Spasm (Printzmetal’s angina)
• Pericarditis
• Brugada Syndrome
• LVH
• Noncardiac
• Metabolic: Hyperkalemia, Hypercalcemia
• Pneumothorax
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Myocardial injury
Pericarditis
Early repolarization
Aneurysm
Kusumoto, ECG Interpretation: From Pathophysiology to Clinical Application 2009
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Clinical Use of the ECG
©2011 MFMER
Chest pain
Presence or
absence of
“structural heart
disease”
Ischemia
Other
Syncope
Palpitations
SOB/fatigue
“Orphans”
“Now that’s
Interesting”
Current
Arrhythmia
Bradycardia
Tachycardia
Palpitations “You are not really having fun until your heart rate is
twice normal”
Keith Oken, 2nd Yr Medicine
Resident UCSF
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Wide Complex Tachycardia (Only four
kinds of tachycardia)
Kusumoto FM, Cardiovascular Pathophysiology Hayes Barton Press 2004
VT
SVT
with aberrancy
Anterograde
AP
conduction
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Causes of WCT
• Ventricular tachycardia
• SVT with aberrant conduction
• Anterograde AP conduction
• Ventricular pacing
• (Metabolic)
©2011 MFMER
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Causes of WCT
• Ventricular tachycardia
• SVT with aberrant conduction
• Anterograde AP conduction
• Ventricular pacing
• (Metabolic)
©2011 MFMER
81%
14%
5%
0
0
Ahktar et al Ann Int Med 1988
Of the patients with VT:
• VT 32%
• “SVT with aberrancy” 35%
• “Who knows” 33%
Ahktar’s Rule: “Do you have Heart Disease?” or
“Have you had a Heart Attack?”
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ECG evaluation of WCT
• “Homan’s signs”
• A-V relationship
• QRS morphology
• Algorithms
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ECG evaluation of WCT
• “Homan’s signs”
• A-V relationship
• QRS morphology
• Algorithms
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ECG evaluation of WCT
• “Homan’s signs”
• Rate, regularity
• Axis (“Northwest” Axis)
• QRS width (“Wider QRS a Disease”)
• A-V relationship
• QRS morphology
• Algorithms
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ECG evaluation of WCT
• “Homan’s signs”
• Rate, regularity
• Axis (“Northwest” Axis)
• QRS width (“Wider QRS a Disease”)
• A-V relationship
• QRS morphology
• Algorithms
![Page 44: Pregnancy and the Heart - ACP](https://reader031.vdocuments.us/reader031/viewer/2022012020/61db1709152e027c620aa5df/html5/thumbnails/44.jpg)
Kusumoto FM. ECG Interpretation: From Pathophysiology to Clinical Application 2009
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ECG evaluation of WCT
• “Homan’s signs”
• A-V relationship
• Use a wide angle lens
• Initiation?
• Look for AV dissociation, not AV association”
• QRS morphology
• Algorithms
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ECG evaluation of WCT
• “Homan’s signs”
• A-V relationship
• Use a wide angle lens
• Initiation?
• Look for AV dissociation, not AV association”
• QRS morphology
• Algorithms
![Page 47: Pregnancy and the Heart - ACP](https://reader031.vdocuments.us/reader031/viewer/2022012020/61db1709152e027c620aa5df/html5/thumbnails/47.jpg)
Concordance
• Precordial QRS complexes all in the same “direction.”
Positive concordance
Negative concordance
V1 V6
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“RBBB Morphology”
V1
VT
SVT
V6
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“LBBB morphology”
“Notch”
V1
R > 30 ms
R-S > 70 ms
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ECG evaluation of WCT
• “Homan’s signs”
• A-V relationship
• QRS morphology
• Concordance
• “plump” initial deflection
• “Aberrancy looks like aberrancy”
• Algorithms
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What to do? “A practical approach?”
• Pretest probability
• AV Dissociation
• QRS morphology (aberrancy looks like aberrancy):
• Concordance
• Positive in aVR
• “Plump” initial activation
• Acknowledge shortcomings, treat acutely as VT, EPS?
©2011 MFMER
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Bernath P and Kusumoto FM. ECG Interpretation on the Spot. Wiley and Sons 2011
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Kusumoto FM. ECG Interpretation: From Pathophysiology to Clinical Application 2009
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Kusumoto FM. ECG Interpretation: From Pathophysiology to Clinical Application 2009
1. Atrial fibrillation with RBBB
2. Multifocal atrial tachycardia with RBBB
3. Ventricular tachycardia
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Kusumoto FM. ECG Interpretation: From Pathophysiology to Clinical Application 2009
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“Wide, irregular, and very very fast”
Kusumoto, ECG Interpretation: from Pathophysiology to Clinical Application 2009
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Wide Complex Tachycardia
Kusumoto FM, Cardiovascular Pathophysiology Hayes Barton Press 2004
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Clinical Use of the ECG
©2011 MFMER
Chest pain
Presence or
absence of
“structural heart
disease”
Ischemia
Other
Syncope
Palpitations
SOB/fatigue
“Orphans”
“Now that’s
Interesting”
Current
Arrhythmia
Bradycardia
Tachycardia
Palpitations
![Page 60: Pregnancy and the Heart - ACP](https://reader031.vdocuments.us/reader031/viewer/2022012020/61db1709152e027c620aa5df/html5/thumbnails/60.jpg)
ECG Interpretation for the Internist: ST changes and Ischemia
• Clinical story first, ECG is adjunctive at best
• Normal Repolarization (T waves)
• Characteristic changes with myocardial ischemia/injury
• Dynamic changes with Sx
• Localization to a specific region of the heart
• Always look for ST segment elevation first
• Reciprocal changes
• “Fake-outs”
©2011 MFMER
![Page 61: Pregnancy and the Heart - ACP](https://reader031.vdocuments.us/reader031/viewer/2022012020/61db1709152e027c620aa5df/html5/thumbnails/61.jpg)
ECG Interpretation for the Internist: ST changes and Ischemia
• Clinical story first, ECG is adjunctive at best
• Normal Repolarization (T waves)
• Characteristic changes with myocardial ischemia/injury
• “Fake-outs”
• Aneurysm
• Pericarditis
• Early Repolarization
• Metabolic (Hyperkalemia, Hypercalcemia)
©2011 MFMER
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ECG Summary: “A practical approach?”
• Pretest probability/pacemaker?
• AV Dissociation
• QRS morphology (aberrancy looks like aberrancy):
• Concordance
• Positive in aVR
• “Plump” initial activation
• Acknowledge shortcomings (understand the algorithms)
• Treat acutely as VT, EPS?
©2011 MFMER
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