bryan heart · neurocardiogenic syncope mechanism –venous pooling vr and vigorous contraction of...
TRANSCRIPT
9/2/2015
1
Bryan Heart
2015 Bryan Heart Fall Cardiology Conference
Andrew Merliss, MD, FACC, CDRS, FHRS
Director of Cardiac Arrhythmia Service
Bryan Heart
Unknown ECGs for the Clinician
Disclaimer
Advisory Board for Medtronic Co
Clinical Research Projects Medtronic and St. Jude Co
9/2/2015
2
Case presentation:26 year old male gun salesman was driving west on route 80 near York when he woke up in a field
No recollection of events
No prior history of syncope or epilepsy
No family history of syncope (no hx of QT , HCM)
On no medications, has a normal PE and ECG
Hobby of posting dash cam recordings on the internet of bad drivers
…and had a dash cam in his car.
This patient:A. 1. Probably has epilepsy and
had a seizure
B. 2. Will probably need a pacemaker or a defibrillator
even though he is only 26.
C. 3. Has had several million hits when he posted this on YouTube.
1. Pro
bably
has
epilepsy
a..
2. W
ill p
robab
ly n
eed a p
...
3. Has
had seve
ral m
illio
n hi..
0% 0%0%
9/2/2015
3
Neurocardiogenic syncope
Mechanism – venous pooling � VR and vigorous contraction of “empty LV.” This stimulates ventricular mechanoreceptors and afferent (C-fiber activity sympathetic inhibition and parasympathetic stimulation via NTS)
– Vasodilation (Vasodepressor type)
– Bradycardia, Heart Block (Cardioinhibitory)
– Mixed
– Hypotension, Syncope
Tilt Table Test for Syncope
Abnormal responses seen during positive tilt test:
• Hypotension (Vasodepressor)
• Cardioinhibitory (Brady, Heart block, asystole—can be dramatic)
• Mixed
9/2/2015
4
Tilt Table
Response
in Patient
with
Neurally-
Mediated
Syncope
Sra JS. Ann Intern Med. 1991;114:1013-1019.
9/2/2015
5
Treatment should include:
A. Reassurance that recurrence is unlikely
B. Beta blockers
C. Beta blockers, midodrine, support hose, increased salt and volume intake
Reassura
nce th
at re
currence
...
Beta b
lock
ers
Beta b
lock
ers, m
idodrin
e, ...
0% 0%0%
The following ECG was taken on a
previously healthy 24 year old medical
student with a normal Physical Exam
9/2/2015
6
Which of the following is trueA. 1. He is unlikely to live
into his sixties
B. 2. He may have had a recent unrecognized PE
C. 3. He has a high risk of needing a future pacemaker
D. 4. He could never be accepted into the Air Force or Marine Corp with this ECG
1. He is
unlik
ely to
live
into
h..
2. He m
ay hav
e had a
rece
nt...
3. He h
as a h
igh ri
sk o
f need...
4. He c
ould n
ever b
e acce
pte...
0% 0%0%0%
If he had had a Pulmonary Embolus his rhythm would most likely be:
A. 1. Normal sinus
B. 2. Atrial fibrillation
C. 3. Atrial flutter
D. 4. Sinus tachycardia
E. 5. Ventricular
tachycardia 1. Norm
al sin
us
2. Atr
ial f
ibrilla
tion
3. Atr
ial f
lutt
er
4. Sin
us tach
ycard
ia
5. Ven
tric
ular t
achyca
rdia
0% 0% 0%0%0%
9/2/2015
7
Right Bundle Branch Block
A. 1. 1.8 per 1000 healthy Air Force Personnel between age 16 and 55
B. 2. Higher incidence at altitude
C. 3. Associated with acute MI, ASD, Ebsteins Anomaly, Chagas Dz, CMP
1. 1.8
per
1000
healthy A
ir F
or..
2. Hig
her inci
dence a
t altitude
3. Ass
ociate
d with a
cute
MI,.
..
0% 0%0%
The insect in the preceding slide is associated with the most common world wide cause of RBBB
A. True
B. False
True
False
0%0%
9/2/2015
8
The following ECG shows:
A. 1. Obvious
pacemaker malfunction
B. 2. Proper pacemaker function
1. Obvi
ous pace
mak
er m
alfu...
2. Pro
per pace
make
r funct
ion
0%0%
This patient has:
A. 1. Ventricular
Tachycardia
B. 2. An Acute MI
C. 3. Bundle Branch
Block
D. 4. Coronary Spasm
1. Ventr
icula
r Tach
ycard
ia
2. An A
cute
MI
3. Bundle
Bra
nch B
lock
4. Coro
nary S
pasm
0% 0%0%0%
9/2/2015
9
This patient has:
A. 1. Mobitz I
B. 2. Mobitz II
C. 3. Neither
1. Mobit
z I
2. Mobit
z II
3. Nei
ther
0% 0%0%
9/2/2015
10
This patient has:
A. 1. Mobitz I block
B. 2. Mobitz II block
C. 3. Can’t tell
1. Mobitz
I blo
ck
2. Mobitz
II b
lock
3. Can’t
tell
0% 0%0%
9/2/2015
11
This patient has:
A. 1. Mobitz I block
B. 2. Mobitz II block
C. 3. Can’t tell
1. Mobit
z I b
lock
2. Mobitz
II b
lock
3. Can
’t te
ll
0% 0%0%
9/2/2015
12
This patient has:
A. 1. Should be
immediately defibrillated
B. 2. Has clean teeth
C. 3. Should be sent to
the neurologist
1. Should
be im
media
tely
de...
2. Has c
lean
teeth
3. Should
be se
nt to th
e neu...
0% 0%0%
9/2/2015
13
This patient:
A. 1. Is having a cardiac
arrest
B. 2. Has a
disconnected ECG lead
C. 3. Needs a defibrillator
1. Is h
aving a
card
iac arr
est
2. Has a
dis
connect
ed ECG
lead
3. Needs
a defib
rilla
tor
0% 0%0%
45 y.o. M with C/P, 95% RCA Rx stent post EF 45% He needs:
A. 1. A life vest for 45
days then ICD
B. 2. Immediate ICD
implantation
C. 3. No life vest, no
ICD
1. A li
fe v
est fo
r 45 d
ays the...
2. Im
media
te IC
D im
planta
tion
3. No li
fe v
est, n
o ICD
0% 0%0%
9/2/2015
14
This patient:
A. 1. Had a recent viral infection and now presents with pleuritic chest pain
B. 2. Is having an MI
C. 3. Is a healthy black male with early repolarization pattern
1. Had a
rece
nt vira
l infe
ctio
...
2. Is h
aving an M
I
3. Is a
health
y bla
ck m
ale w
it...
0% 0%0%
This patient:
A. 1. Slow V-Tach
(Idioventricular rhythm)
B. 2. Is having an MI
C. 3. Has atrial
fibrillation and is having an MI
1. Slo
w V
-Tach
(Idio
ventricu...
2. Is havi
ng an M
I
3. Has
atria
l fib
rilla
tion a
nd ..
0% 0%0%
9/2/2015
15
This patient:
A. 1. Chest Pain
B. 2. A headache
1. Chest
Pain
2. A h
eadac
he
0%0%
9/2/2015
16
This patient:
A. 1. Chest Pain
B. 2. A headache
1. Chest
Pain
2. A h
eadac
he
0%0%
19 year old Black male collapsed playing basketball
A. 1. Benign
hypertrophy of healthy black males
B. 2. Has untreated HTN and LVH
C. 3. May have hypertrophic
cardiomyopathy1. B
enign h
ypertr
ophy of h
e...
2. Has
untreate
d HTN
and L
VH
3. May h
ave
hyper
trophic
c...
0% 0%0%
9/2/2015
17
This patient
A. 1. Is hyperkalemic
B. 2. Is having an MI
1. Is h
yperk
alem
ic
2. Is havi
ng an M
I
0%0%
9/2/2015
18
This patient
A. 1. Hyperkalemic
B. 2. Is having an acute
MI
1. Hyperk
alem
ic
2. Is havi
ng an a
cute
MI
0%0%
This patient
A. 1. Has hyperkalemia
B. 2. Is having an MI
1. Has
hyperkal
emia
2. Is h
aving a
n MI
0%0%
9/2/2015
19
This patient
A. 1. Has bulimia and
takes diuretics and laxatives
B. 2. Is hyperkalemic and needs dialysis
1. Has b
ulimia
and ta
kes diu
r...
2. Is h
yperkale
mic
and nee
ds...
0%0%
If the patient:A. 1. Develops Atrial
fibrillation give Sotolol and then cardiovert
B. 2. Develops pneumonia give erythromycin
C. 3. Develops a fungal infection give Ketaconozole
D. 4. Develops depression give Elavil
E. 5. None of the above1. D
evelops A
tria
l fib
rilla
tion...
2. Develo
ps p
neumonia
give...
3. Develo
ps a fu
ngal
infe
ctio
...
4. Develo
ps depre
ssio
n giv
e...
5. None o
f the a
bove
0% 0% 0%0%0%
9/2/2015
20
Causes of QT prolongation
A. 1. Congenital ion
channelopathies
B. 2. Drugs—Acquired
channelopathies
C. 3. Electrolyte
abnormalities
1. Congenita
l ion c
hannelop...
2. Dru
gs—Acq
uired ch
annel...
3. Ele
ctro
lyte
abnorm
alitie
s
0% 0%0%
9/2/2015
21
This arrhythmia originated in the:
A. 1. Atrium
B. 2. Ventricle
1. Atr
ium
2. Ven
tricle
0%0%
This patient
A. 1. Has V tach
B. 2. Has SVT (with
aberrancy)
1. Has V
tach
2. Has S
VT (with
aber
rancy
)
0%0%
9/2/2015
22
He has an EF of 35%, has been on ACEI and BB for 3month and subsequently has an ICD implanted. Which of the following are true:
A. 1. V tach may be terminated by anti tachy pacing
B. 2. V tach can be terminated by ICD shock
C. 3. The ICD can prevent Sudden Death by stopping a bullet
D. 4. All are true
1. V t
ach m
ay be te
rmin
ated...
2. V ta
ch can b
e term
inat
ed ..
3. The IC
D can p
reve
nt Sudd..
4. All
are tr
ue
0% 0%0%0%
ICD Therapies
Differentiating VTach from SVT with aberrancy
Width of QRS
Bizarre axis
AV dissociation
“Rabbit ears”
Concordant precordial QRS pattern
9/2/2015
23
This patient
A. 1. Needs a
pacemaker
B. 2. Needs a
defibrillator
1. Nee
ds a p
acem
aker
2. Nee
ds a d
efibril
lato
r
0%0%
9/2/2015
24
This patient
A. 1. Has a fever of 102
and sinus tachycardia
B. 2. Has SVT
1. Has a
feve
r of 1
02 and si
n..
2. Has S
VT
0%0%
This patient
A. 1. Has WPW
syndrome
B. 2. Has a Left Bundle
Branch Block
1. Has
WPW
syndro
me
2. Has a
Left
Bundle
Bra
nch ..
.
0%0%
9/2/2015
25
This patient
A. 1. Atrial fibrillation
B. 2. Ventricular
tachycardia
1. Atr
ial f
ibrilla
tion
2. Ven
tricula
r tach
ycard
ia
0%0%