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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]