ecg quiz: difficult, but insightfuliseindia.org/ecg_presentation/12.dr.yash lokhandwala.pdf · ecg...
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ECG Quiz: Difficult, but Insightful
Joep Smeets
Yash Lokhandwala
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A 63 year old woman was treated with lithium because of a bipolar
syndrome. The last two days she is lethargic and has repeated syncope.
Physical examination, apart from a slow and irregular heart rate did not
reveal any abnormality.
1
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A. CHB, PACs B. Sick sinus syndrome
C. Escape rhythm, retrograde conduction D. Sinus bradycardia, wandering pacemaker
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Boulaksil et al. Neth Heart J 2013
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57 yr old woman, ASD closure done 11 years ago. Past H/O Pulmonary TB
Admitted for Palpitations
2
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Few minutes after IV Diltiazem
Courtesy: Dr. Ronak Ruparella, Nanavati Hospital
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Next Day
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Again SVT
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10 mins after IV Diltiazem
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A. Atypical AVNRT B. Atrial tachycardia C. Atrial flutter D. B & C E. Coumel/PJRT
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36 hrs after successful resuscitation the following ECG was made of an 84 year
old woman. In the past she had hypertension and a TIA. She stopped all
medication 4 years ago. GFR was 27 ml/min (diminished) and high sensitive
troponin was elevated.
3
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LBBB is explained by:
A. Phase 3 block B. Phase 4 block
C. Phase 3 & Phase 4 block D. Fusion with PVC
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570
570
PVC PVC
1140 1140
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570
570
PVC PVC
1140 1140
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SGARBOSSA CRITERIA 1996 New England Journal of Medicine 334 (8): 481–487
• ST elevation ≥1 mm in a lead with a positive QRS
complex (ie: concordance) - 5 points
• ST depression ≥1 mm in lead V1, V2, or V3 - 3 points
• ST elevation ≥5 mm in a lead with a negative
(discordant) QRS complex - 2 points
• ≥3 points = 90% specificity of STEMI (sensitivity of
36%)
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2.5 hrs after resuscitation
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Which is the culprit vessel? Where is it occluded?
4
A. Proximal LAD, prior to S1 B. LAD, between S1 and D1 C. Left main
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A 72 yr old man had a MI 10 years ago; no reperfusion therapy was done at that time.
His complaints are: palpitations since one hour; he did not lose consciousness. The
following ECG was recorded during his palpitations:
5
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The AV relationship is:
1. AV Wenckebach
2. 1:1
3. VA Wenckebach
4. AV dissociation
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72 yr old woman 6
A. Intermittent preexcitation B. Phase 4 LAFB C. Artefact D. None of the above
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The arrows are exactly equal
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You, as consultants, are asked for your opinion in a 8 year old boy; he suffered from many episodes of loss
of consciousness; he is an active normal developing boy. Several episodes of syncope have been observed:
the attacks last for 1-2 minutes, sometimes urinary incontinence is noted; he has seizures of arms and legs.
Immediately after the attacks he is disoriented in time and place. The attacks can occur during playing
soccer in the street. He is treated by a neurologist with ant-epileptic medicine; this gives an improvement but
the attacks are still present. Your opinion and approach please.
7
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120 watt
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CPVT (Catecholaminergic polymorphic VT)
• Ryanodine receptor gene (RyR2) positive
• Betablocker in maximally tolerated dose
• Flecainide added to betablocker
– Inhibits CA release from sarcoplasmatic reticulum
Carvedilol
*Kannankeril et al JAMA Cardiol. 2017;2(7):759-766. Efficacy of Flecainide in the Treatment of Catecholaminergic Polymorphic Ventricular Tachycardia- A Randomized Clinical Trial
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Holter
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8
A 45 yr old man with a past history of ICCU admission for chest pain
A. SVT B. VT
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8a After reversion to sinus rhythm
A. SVT with old anterior MI/RBBB B. Scar VT
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A 55 year old woman comes to your outpatient clinic with exercise related shortness
of breath and chest discomfort; her family history is positive for coronary artery
disease; she uses lipid lowering drugs, aspirin and ACE-I (for hypertension). Physical
examination is within normal limits. During exercise testing the following 12 lead ECG
is recorded…
9
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The narrow QRS complexes can be explained by:
A. Additional delay in the right bundle
B. Fusion with a PVC from the LV
C. Supernormal conduction in the left bundle
D. None of the above
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1 2
1 2
3
3
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Threshold potential
Action potential
1
2
3
1 2 3 Left Bundle
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Interval 465
VPB
930
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31 years male. C/O palpitations, chest discomfort. No syncope / near-syncope
Similar complains 1 month ago - relieved by some medication given by GP
10
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Soon after, another ECG of the same patient. Stable, BP 110/70
Drug of choice: A. Adenosine B. Verapamil C. Lignocaine D. Amiodarone
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After Verapamil - 15mg
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After 1 week
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A 49 year old man is walking on the second day of a march (4 days in a row, every day
50 km) and is not well; he feels chest discomfort; it started in the morning, but is
increasing during his march; he did not have this before; apart from ‘flu’ 4-5 days ago he
has no medical history; family history is negative for coronary heart disease. The
following ECG is made at the first heart aid:
11
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Blood examination
• CK max 2212 U/L
• Trop I > 150 μg/L ( normal < 20)
• Trop T 2793 ng/L (normal < 14 )
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24 hours later
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After 2 days
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65 yr old man. Old VVI PM. Admitted with chest pain and sweating
12
Does the ECG suggest ACS? A. Yes B. No C. Can’t say because of paced rhythm
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Further course
• The patient was given aspirin, clopidogrel and advised to undergo coronary angiography
• He refused angiography, so streptokinase was administered
• The Troponin was elevated, the posterior wall was hypokinetic
Courtesy: Dr Mandar Shah, Tata Main Hospital, Jamshedpur
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After 3 days
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After stenting
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After PTCA