SHIVDA PANDEY, PGY-6MARK VILLALON, PGY-6

BOSTON MEDICAL CENTERCARDIOVASCULAR FELLOWS

ECG Master SessionSENIOR RESIDENT EDITION

What is your ECG diagnosis? PCP Clinic Visit

65 year old male with PMH hypertension and active smoking is in your clinic for an initial evaluation.

He has no complaints and feels well. Routine ECG is performed in light of his cardiac risk factors

and reveals the following:

What is your diagnosis?

A. I know the diagnosis and can teach this concept to my 3rd year med student

B. I’m pretty sure about this diagnosisC. I’m not very sure about this diagnosisD. What does the automated read say?

Diagnosis

Step 1: Normal sinus rhythm** Always start with the

rhythm**

“NSR is not “There’s a P before every QRS”

“There’s a P before every QRS” This does not define NSR Can be seen in flutter, a-tach etc

Sinus rhythm = Upright P’s in: Lead I, II and aVF

Right to left activation

Diagnosis

1. NSR2. Wow, is that QRS wide or something?

Sinus rhythm and the wide QRS

100 msec 120 msec

Normal QRS width IVCD“Incomplete RBBB”“Incomplete LBBB”

LBBBRBBBIVCD

South Shore Plaza

Fast Slow

LBBB: RV contracts, then LV contracts

V6 V6

Left Bundle Branch Block

QRS > 120 msecV5-V6: Broad R waveI + aVL: Absence of Q wave

RBBB: Left ventricle contracts, then right ventricle contracts

QRS > 120 msec

V1-V2: RSR’Lateral leads:

Deep terminal S wave

A. IVCDB. RBBBC. LBBB

A. IVCDB. RBBBC. LBBB

A. IVCDB. RBBBC. LBBB

“When I go fast, I go wide”

Rate-related aberrancy Usually RBBB,

but can be LBBB Refractoriness Clinical

significance: At faster rates, need to differentiate VT vs SVT with aberrancy

PA catheter insertion Pt with LBBB

Complete heart block. Hopefully there’s an escape rhythm. Watch the monitor during insertion.

55M with PMH DM2 and smoking p/w 1hr of “crushing” chest pain. ECG from last

week with NSR and normal QRS width. Dx? Mx?

A. New LBBB. Wait for the enzymes.

B. New LBBB. Admit to Obs unit.

C. New LBBB. Call cards fellow to activate the cath lab STAT.

55M with PMH DM2 and smoking p/w 1hr of “crushing” chest pain. ECG from last week with NSR and normal QRS width. Dx? Mx?

A. Old LBBB. Wait for the enzymes.B. Old LBBB. Admit to Obs unit.C. Old LBBB + acute MI. Call cards fellow

STAT.D. This is a trick question.

Discordant:QRS deflection is

opposite of T wave deflection

Concordant:QRS deflection is

the same of T wave deflection

Normal in LBBB and paced rhythm

How to diagnose an acute MI in pt with LBBB (or paced rhythm)

ST elevation ≥1 mm in a lead with upward (concordant) QRS complex - 5 points

ST elevation ≥5 mm in a lead with downward (discordant) QRS complex - 2 points

ST depression ≥1 mm in lead V1, V2, or V3 - 3 points

≥3 points = 90% specificity of STEMI (sensitivity of 36%)

Thank you