EKG Workshop -

Beyond the Basics

Dr. Ross MacKenzie FRCPC FACC

2012 AAIM Annual Meeting – San Diego 1

ECG Workshop

Objectives:

•Beyond the basics

•Common ECG underwriting challenges

•Newer ECG patterns with mortality implications

•Focus on ECG morphology

2

Asymptomatic 42 year old female

4

Baseline ECG Right Arm/Right Leg Exchange

Right Arm/Right Leg Lead Exchange

5

Left Arm/Right Leg Lead Reversal

Baseline ECG Left Arm/Right Leg Reversal

6

Bilateral Arm-Leg Lead Reversal

Baseline ECG Bilateral Arm-Leg Lead Reversal

48 Year Old Man With a Pacemaker for Congenital Heart Block

8

LBBB Pattern Produced by Proper Pacemaker

Catheter Position in RV Apex

9

55 Y. O. Male - PH of Possible MI - Pre-ex. Test ECG

10

Mason Likar Exercise ECG Electrode Placement Configuration

11

Standard ECG Showing Previous Inferior Myocardial Infarction

12

47 Year Old Man with History of Previous MI

Asymptomatic 54 Year Old Male Applicant

13

56 Year Old Male Entrepreneur Who Had Chest Discomfort One Year Ago While

Travelling in Southeast Asia

41 Y. O. Man - History of Erythema Nodosum Age 14

Fragmented QRS Patterns

38-year old stockbroker – ECG for “age and amount”

Courtesy of Dr. M. Clark

18

ECG from 5 years prior to the application

Courtesy of Dr. M. Clark

19

Horizontal Vector Loop of Normal R wave Progression

20

Anteroseptal Infarction

Horizontal Plane

21

Left Ventricular Hypertrophy

Horizontal Plane

22

The P Wave in V2 and Technical Errors Recording the Chest

Leads

23

Changing P-Wave Morphology in Lead V2

Ilg KJ, et al, Am J Med 2012; 125:23.

49 year old woman who had a severe episode of gastroenteritis after climbing Mount

Kilimanjaro in Tanzania

25

Dilated Cardiomyopathy

26

40 year old asymptomatic male applicant

36 year old asymptomatic male college basketball coach

36 year old asymptomatic male

29

Normal Precordial ST Segment Elevation

24 year old woman with history of palpitations

32

Ebstein’s Anomaly

33

32 year old male with systolic murmur at the apex

34

Primum Atrial Septal Defect Secundum Atrial Septal Defect

Secundum Atrial Septal Defect

35

36

The “Crochetage Sign “ in Atrial Septal Defects

40 Year Old Male – Tetralogy of Fallot Repair Age 5

25 year old asymptomatic male

Brugada ECG Patterns

Brugada Type 1 Pattern

40

Borderline Brugada PatternDrug Challenge

Saddleback Pattern Changes When V1 and V2 Are Moved To The Second and Third

Intercostal space (V2IC2 and V2IC3) Overlying the Right Ventricular Outflow Tract

Meregalli P G et al. Cardiovasc Res 2005;67:367-378

46 year old asymptomatic college professor

43

44

Incidence of T wave Inversion Beyond V1 and V2

In ages 19-45

< 4% in women

< 1% in men

In middle-aged subjects 36-50

< 0.7%

Marcus F. Am J Cardiol 2005; 95:1070

Aro AL. Circulation 2012; 125:1272

21 year old asymptomatic male

45

25 year old asymptomatic male

46

47

Epsilon Wave