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OFFICE ECG INTERPRETATION JOHN HAMATY D.O. FACC, FACOI SJHG SEPTEMBER 10TH 2016 55 yr old male with history of HTN presents for routine physical. He is asymptomatic and exercises regularly. His physical exam is normal. Which is the next most appropriate step? A) Send the patient to the ER B) Refer to cardiology C)Recommend conservative treatment D)Beta block and refer for a stress test. LEFT BUNDLE BRANCH BLOCK Correct answer is C The prevalence of LBBB, which appears to increase with age, has been estimated between 0.2 to 1.1 percent of the general population. LBBB most commonly results not from a single clinical entity but rather from slowly progressive degenerative disease involving the conduction system. The prognosis in patients with LBBB is related largely to the type and severity of any concurrent underlying heart disease and to the possible presence of other conduction disturbances: Among asymptomatic patients, LBBB appears to have minimal effect on outcomes in younger, apparently healthy subjects, while LBBB in older individuals has been associated with an increase in mortality • For asymptomatic patients with an isolated LBBB and no other evidence of cardiac disease, no specific therapy is required. If symptoms or increased risk, consider pharmacologic stress test. 85 YR OLD FEMALE PRESENTS WITH MILD RETROSTERNAL CHEST PAIN. HER PMH IS SIGNIFICANT FOR HTN, DM AND HYPERLIPIDEMIA. WHAT IS THE NEXT MOST APPROPIRATE STEP A) Recommend Cardiac Cath B) Nuclear Stress Test C) Conservative Treatment D) Beta Blocker and send directly to the ER Right Bundle Branch Block Correct Answer is B • The prevalence of RBBB, which appears to increase with age, has been estimated between 0.2 to 0.8 percent of the general population. • The prognosis in patients with RBBB is related largely to the type and severity of any concurrent underlying heart disease and to the possible presence of other conduction disturbances. Long-term outcomes are generally excellent in patients without apparent heart disease, while those with RBBB in the setting of underlying cardiac disease generally have worse outcomes than those without bundle branch block. • For asymptomatic patients with an isolated RBBB (complete or incomplete) and no other evidence of cardiac disease, no further diagnostic evaluation or specific therapy is required. However, permanent pacemaker insertion is indicated for patients with RBBB who develop symptomatic conduction system disturbances, such as third degree or type II second degree AV block that is not associated with a reversible or transient condition • Patients with isolated chronic RBBB (complete or incomplete) are generally asymptomatic and do not require further diagnostic evaluation for RBBB or placement of a pacemaker or any other specific therapy. PROGNOSIS The prognosis in patients with RBBB is related largely to the presence, type, and severity of underlying heart disease or associated conduction abnormalities: ●In patients with known or suspected cardiovascular disease (CVD), RBBB is an independent predictor of all-cause mortality. Several large cohort studies have shown an increase in mortality among patients with CVD and complete RBBB. As an example, among 12,346 women with CVD (excluding those with LBBB) who participated in the Women's Health Initiative trial, there was a significantly greater risk of death from coronary heart disease but not overall mortality among women with RBBB compared with no BBB. The presence of RBBB after a myocardial infarction is also associated with an increase in mortality. 55 Yr old male presents for evaluation of occasional headaches. His BP in your office is 188/106mmHg. Your start appropriate medical therapy and on return visit, his BP is now 140/82mmHg. The Next Most Appropriate Step in the Evaluation is ? A)Stress Testing B) Refer to Cardiology C) Echocardiography and routine stress testing D)Echocardiography LVH with ST and T changes Correct answer is D Left ventricular hypertrophy (LVH) is associated with increased incidence of heart failure, ventricular arrhythmias, death following myocardial infarction, decreased LV ejection fraction, sudden cardiac death, aortic root dilation, and a cerebrovascular event. The increase in cardiovascular risk is directly related to the degree of increase in left ventricular mass. ●Left ventricular hypertrophy can be diagnosed either by ECG or by echocardiography. Echocardiography is more sensitive and is the preferred test. ●The increased cardiac risk associated with LVH is due in part to myocardial ischemia. The development of heart failure with LVH results from depressed left ventricular systolic function and/or diastolic dysfunction. Electrical remodeling from LVH is associated with increased risk of atrial fibrillation, ventricular arrhythmias, especially torsades de pointes, and sudden death. ●The regression of LVH is associated with a reduction in cardiovascular risk and improved cardiac function. The use of antihypertensive agents, weight loss, or dietary sodium restriction decreases cardiac mass in patients with LVH. But repeat echo is not recommended since it has no effect on therapy. Stress testing may be indicated for assessment of BP control. ●Regression of LVH is associated with use of angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), the direct renin inhibitor, some calcium channel blockers, and some sympatholytic agents. Regression of LVH is less with diuretics and beta blockers and is largely absent with direct vasodilators . However, the clinical importance of this finding is uncertain, and therefore the choice of antihypertensive agent is generally based on other factors. 82 yr old female presents to your office for new patient evaluation from an ECF. She doesn’t remember much history and the above ECG is performed. Which is the next most appropriate step? A)Send directly to the ER B) Refer her to Cardiology C) Beta Block the patient D)Recommend routine follow up in 3 months. A-V SEQUENTIAL PACEMAKER CORRECT ANSWER IS B The key to pacemaker assessment from primary care stand point is to make sure the rate is 60 b/min or greater. Most conventional pacing parameters set the rate to 60 and this tells you the device is functionally normally. If the rate is < 60b/min then have pt evaluated immediately as the battery may be an issue. Pacemakers almost NEVER FAIL. IF you think its failing it isn’t! (I’ve made that mistake) Intermittent pacer spikes mean the intrinsic heart rate is taking over the heart beat. 78 yr old female presents with palpitations, fluttering and fatigue. She has not passed out and does not have chest pain. Her PMH is positive for HTN. She has no other risk factors. WHAT IS THE NEXT MOST APPROPRIATE STEP? A)Send directly to the emergency room B) Refer directly to cardiology C) Place on ASA 325 mg and add a calcium channel blocker for rate control D)Add a beta blocker for rate control and add anticoagulation with warfarin or NOAC ATRIAL FIBRILLATION WITH RAPID VENTRICULAR RESPONSE CORRECT ANSWER IS D Atrial fibrillation (AF) is the most common cardiac arrhythmia that can have adverse consequences related to a reduction in cardiac output (symptoms) and to atrial and atrial appendage thrombus formation (stroke and peripheral embolization). In addition, affected patients may be at increased risk for mortality. ●Hypertensive heart disease and coronary heart disease are the most common underlying disorders in developed countries associated with atrial fibrillation. This is why Beta blockers are initial drugs of choice. ●Patients are classified as having new onset, paroxysmal, persistent, longstanding persistent, or permanent AF. ●Essential information from the patient’s history, physical examination, electrocardiogram, and a transthoracic echocardiogram should be obtained at the time of diagnosis and periodically during the course of the disease. Additional laboratory testing, such as thyroid stimulating hormone assay, may be necessary. The two principal management decisions for patients are: •Does the patient need long-term antithrombotic therapy? All patients whose risk of embolization exceeds the risk of bleeding are candidates for such therapy. •Should the patient be managed with either a rate or a rhythm control strategy? This should be determined based on severity of symptoms, presence of structural heart disease, adequacy of rate control during episodes of atrial fibrillation, and the patient’s preference for using antiarrhythmic drug therapy or undergoing ablation-based interventions. ●In the absence of a reversible precipitant, AF is typically recurrent. CHAD2SVASC2 SCORE TO ASSESS STROKE RISK Workup consists of Echo, pharmacologic stress test and labs(TFS, lytes) 78 yr old male presents with new onset palpitations. They began 2 weeks ago and get worse with activity but sometimes with rest. He does not get dizzy. PMH: HTN, smoking and hyperlipidemia. WHAT IS THE NEXT MOST APPROPRIATE STEP? A)24 hr Holter, echo and stress testing B) Conservative therapy C) 24 hr Holter D)Beta blocker and reassess for recurrent symptoms NORMAL SINUS RHYTHM WITH PVC’S THE CORRECT ANSWER IS A Due to the brief nature of the test, VPBs may not be recorded during a standard ECG. In such cases, ambulatory monitoring should be performed, initially for 24 or 48 hours or, if necessary, for up to 30 days, which will significantly increase the likelihood of detecting VPBs. ●For patients in whom otherwise unexplained VPBs have been identified, the following evaluation should be performed: •Twenty-four-hour ambulatory (Holter) monitor to quantify the frequency of VPBs and determine if they are monomorphic or multimorphic.(20% pvc’S/24 HR is significant) •Echocardiography to assess cardiac structure and function. •Exercise treadmill stress test to evaluate the response of the VPBs to exercise, determine the VPB morphology, determine if sustained or nonsustained ventricular tachycardia (VT) can be induced with exercise, as well as to screen for underlying ischemia. ●In persons found to have frequent VPBs or more importantly repetitive forms of VPBs (couplets or nonsustained VT), further evaluation and management is based on the presence or absence of underlying structural heart disease and/or symptoms. The presence of frequent VPBs should lead to a clinical assessment for the possible presence of underlying structural heart disease, which has prognostic significance and may require specific therapy. 72 yr old female presents with intermittent dizziness and fatigue. It has been ongoing for months. Her PMH is positive for HTN, DM and OA. Meds include Lisinopril, Metformin, ASA, Pepcid and Motrin prn pain and Lipitor. THE NEXT MOST APPROPRIATE STEP IS? A)Reassurance that this ECG is benign and not causing her symptoms B)Send her directly to the ER C)Send to Dr. Hamaty D)Evaluate the pt with an Echo and Stress Testing The correct answer is D For the majority of patients with sinus bradycardia, hints at the underlying cause can be determined from history and physical examination. The aim of the initial evaluation is to establish the presence or absence of symptoms, and any evidence of hemodynamic compromise as a result of the bradycardia. Once hemodynamic compromise has been excluded, the clinician will have to exclude diseases, cardiovascular or other, associated with sinus bradycardia and, most importantly, drugs associated with sinus bradycardia. Patients with evidence of another systemic condition associated with sinus bradycardia (eg, hypothyroidism, infection, etc) should be treated accordingly. •Patients in whom a medication is suspected to be causing the symptomatic bradycardia should have the medication withheld. If the medication is mandatory for the treatment of a comorbid condition (eg, beta blockers for severe angina), a permanent pacemaker may be required. If the symptoms resolve and heart rate improves following the withdrawal of the suspected offending agent, no additional immediate treatment is required. •Patients with no other evidence of a potential cause should be evaluated for sick sinus syndrome. PROGNOSIS — There is no adverse prognostic significance to sinus bradycardia in otherwise healthy subjects. In subjects over the age of 40, for example, there is no adverse effect on longevity RAPID FIRE ECG ANALYSIS A) B) C) D) ACUTE ANTERIOR ISCHEMIA ACUTE ANTERIOR MI ACUTE LATERAL MI ACUTE INFERIOR/LATERAL MI ACUTE INFERIOR/LATERAL MI A) B) C) D) SINUS TAC, RIGHT BUNDLE BRANCH BLOCK WITH AGE INDETERMINENT INFERIOR MI SINUS TAC, LEFT BUNDLE BRANCH BLOCK WITH AGE INDETERMINENT ANTERIOR MI SINUS TAC, RIGHT BUNDLE BRANCH BLOCK WITH AGE INDETERMINENT ANTERIOR MI SINUS TAC WITH ACUTE INFERIOR MI SINUS TAC WITH RIGHT BUNDLE BRANCH BLOCK AND AGE INDETERMINENT INF MI A) B) C) D) NSR NORMAL ECG NSR AGE INDETERMINENT ANTERIOR MI ECTOPIC ATRIAL RHYTHM ACUTE INFERIOR MI ECTOPIC ATRIAL RHYTHM A) B) C) D) NSR ANTERIOR MI NSR ACUTE INFERIOR MI NSR ST DEPRESSION INFERIOR LATERALLY CONSISTANT WITH ISCHEMIA NSR ST DEPRESSION ANTERIORLY CONSISTANT WITH ISCHEMIA NSR ST DEPRESSION INFERIOR LATERALLY CONSISTANT WITH ISCHEMIA REFERENCES Mirvis D, Goldberger AL. Electrocardiography. In: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 10th ed, Mann DL. (Ed), Elsevier/Saunders, Philadelphia 2014. Moon JC, De Arenaza DP, Elkington AG, et al. The pathologic basis of Q-wave and non-Qwave myocardial infarction: a cardiovascular magnetic resonance study. J Am Coll Cardiol 2004; 44:554. Thygesen K, Alpert JS, White HD, Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction. Universal definition of myocardial infarction. Eur Heart J 2007; 28:2525. Zeymer U, Schröder R, Tebbe U, et al. Non-invasive detection of early infarct vessel patency by resolution of ST-segment elevation in patients with thrombolysis for acute myocardial infarction; results of the angiographic substudy of the Hirudin for Improvement of Thrombolysis (HIT)-4 trial. Eur Heart J 2001; 22:769. Schröder K, Wegscheider K, Zeymer U, et al. Extent of ST-segment deviation in a single electrocardiogram lead 90 min after thrombolysis as a predictor of medium-term mortality in acute myocardial infarction. Lancet 2001; 358:1479. Zeymer U, Schröder K, Wegscheider K, et al. ST resolution in a single electrocardiographic lead: a simple and accurate predictor of cardiac mortality in patients with fibrinolytic therapy for acute ST-elevation myocardial infarction. Am Heart J 2005; 149:91. Bogaty P, Boyer L, Rousseau L, Arsenault M. Is anteroseptal myocardial infarction an appropriate term? Am J Med 2002; 113:37. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part VI: acute ischemia/infarction: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society. Endorsed by the International Society for Computerized Electrocardiology. AU Wagner GS, Macfarlane P, Wellens H, Josephson M, Gorgels A, Mirvis DM, Pahlm O, Surawicz B, Kligfield P, Childers R, Gettes LS, Bailey JJ, Deal BJ, Gorgels A, Hancock EW, Kors JA, Mason JW, Okin P, Rautaharju PM, van Herpen G, American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology, American College of Cardiology Foundation, Heart Rhythm Society SO J Am Coll Cardiol. 2009;53(11):1003. John N. Hamaty D.O. FACC, FACOI 1 Brace Road Cherry Hill, NJ 856)482-8900 [email protected]