Download Cardiology/EKG Board Review

Cardiology/EKG
BoardReview
MichaelJ.BradleyD.O.
DME/ProgramDirector
FamilyMedicineResidency
ObjecCves
•  ReviewgeneralmethodforEKGinterpretaCon
•  Reviewspecificpointsof“datagathering”and
“diagnoses”onEKG
•  ReviewtreatmentconsideraCons
•  Reviewclinicalcases/EKG’s
•  BoardexamconsideraCons
EKG
EKG–12Leads
• 
• 
• 
• 
AnteriorLeads-V1,V2,V3,V4
InferiorLeads–II,III,aVF
LeVLateralLeads–I,aVL,V5,V6
RightLeads–aVR,V1
11StepMethodforReadingEKG’s
•  “DataGathering”–steps1-4
–  1.StandardizaCon–makesurepaperandpaper
speedisstandardized
–  2.HeartRate
–  3.Intervals–PR,QT,QRSwidth
–  4.Axis–normalvs.deviaCon
11StepMethodforReadingEKG’s
•  “Diagnoses”
–  5.Rhythm
–  6.Atrioventricular(AV)BlockDisturbances
–  7.BundleBranchBlockorHemiblock
of
–  8.PreexcitaCon
ConducCon
–  9.EnlargementandHypertrophy
–  10.CoronaryArteryDisease
–  11.UgerConfusion
•  TheOnlyEKGBookYou’llEverNeed
MalcolmS.Thaler,MD
HeartRate
•  RegularRhythms
HeartRate
•  IrregularRhythms
Intervals
•  MeasurelengthofPRinterval,QTinterval,
widthofPwave,QRScomplex
QTc
•  QTc=QTintervalcorrectedforheartrate
–  UsesBazeg’sFormulaorFridericia’sFormula
•  LongQTsyndrome–inheritedoracquired
(>75meds);torsadesdeponites/VF;syncope,
seizures,suddendeath
Axis
Rhythm
•  4QuesCons
–  1.ArenormalPwavespresent?
–  2.AreQRScomplexesnarroworwide(≤or≥0.12)?
–  3.WhatisrelaConshipbetweenPwavesandQRS
complexes?
–  4.Isrhythmregularorirregular?
•  Sinusrhythm=normalPwaves,narrowQRS
complexes,1Pwavetoevery1QRScomplex,and
regularrhythm
TypesofArrhythmias
• 
• 
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Arrhythmiasofsinusorigin
Ectopicrhythms
ConducConBlocks
PreexcitaConsyndromes
AVBlock
•  DiagnosedbyexaminingrelaConshipofPwavestoQRS
complexes
•  FirstDegree–PRinterval>0.2seconds;allbeats
conductedthroughtotheventricles
•  SecondDegree–onlysomebeatsareconductedthrough
totheventricles
–  MobitzTypeI(Wenckebach)–progressiveprolongaConofPR
intervalunClaQRSisdropped
–  MobitzTypeII–All-or-nothingconducConinwhichQRS
complexesaredroppedwithoutPRintervalprolongaCon
•  ThirdDegree–Nobeatsareconductedthroughtothe
ventricles;completeheartblockwithAVdissociaCon;atria
andventriclesaredrivenbyindividualpacemakers
BundleBranchBlocks
•  Diagnosedbylookingatwidthand
configuraConofQRScomplexes
BundleBranchBlocks
•  RBBBcriteria:
–  1.QRScomplex>0.12seconds
–  2.RSR’inleadsV1andV2(rabbitears)withSTsegmentdepression
andTwaveinversion
–  3.ReciprocalchangesinleadsV5,V6,I,andaVL
•  LBBBcriteria:
–  1.QRScomplex>0.12seconds
–  2.BroadornotchedRwavewithprolongedupstrokeinleadsV5,V6,I,
andaVLwithSTsegmentdepressionandTwaveinversion.
–  3.ReciprocalchangesinleadsV1andV2.
–  4.LeVaxisdeviaConmaybepresent.
BundleBranchBlocks
Hemiblocks
•  DiagnosedbylookingatrightorleVaxis
deviaCon
•  LeVAnteriorHemiblock
–  1.NormalQRSduraConandnoSTsegmentorTwavechanges
–  2.LeVaxisdeviaCongreaterthan-30°
–  3.NoothercauseofleVaxisdeviaConispresent
•  LeVPosteriorHemiblock
–  1.NormalQRSduraConandnoSTsegmentorTwavechanges
–  2.RightaxisdeviaCon
–  3.NoothercauseofrightaxisdeviaConispresent
BifascicularBlock
•  RBBBwithLAH
–  RBBB–QRS>0.12secandRSR’inV1andV2with
LAH–leVaxisdeviaCon
•  RBBBwithLPH
–  RBBB–RS>0.12secandRSR’inV1andV2with
LPH–rightaxisdeviaCon
PreexcitaCon
•  Wolff-Parkinson-White(WPW)Syndrome
–  1.PRinterval<0.12sec
–  2.WideQRScomplexes
–  3.Deltawavesseeninsomeleads
•  Lown-Ganong-Levine(LGL)Syndrome–
–  1.PRinterval<0.12sec
–  2.NormalQRSwidth
–  3.Nodeltawave
•  CommonArrhythmias
–  ParoxysmalSupraventricularTachycardia(PSVT)–narrowQRS’s
aremorecommonthanwideQRS’s
–  AtrialFibrillaCon–canberapidandleadtoventricular
fibrillaCon
PreexcitaCon
WPW
LGL
SupraventricularArrhythmias
•  PSVT-regular;Pwavesretrogradeifvisible;rate150-250bpm;
caroCdmassage:slowsorterminates
•  Fluger–regular;saw-toothedpagern;2:1,3:1,4:1,etc.block;
atrialrate250-350bpm;ventricularrate½,⅓,¼,etc.ofatrialrate;
caroCdmassage:increasesblock
•  FibrillaCon–irregular;undulaCngbaseline;atrialrate350to500
bpm;variableventricularrate;caroCdmassage:mayslow
ventricularrate
•  MulCfocalatrialtachycardia(MAT)–irregular;atleast3differentP
wavemorphologies;rate–usually100to200bpm;someCmes
<100bpm;caroCdmassage:noeffect
•  PAT–regular;100to200bpm;characterisCcwarm-upperiodin
theautomaCcform;caroCdmassage:noeffect,ormildslowing
SupraventricularArrhythmias
RulesofAberrancy
VentricularTachycardia
Paroxysmal
supraventricular
Tachycardia
ClinicalHistory
Diseasedheart
Usuallynormalheart
CaroCdMassage
Noresponse
Mayterminate
CannonAWaves
Maybepresent
Notseen
AVDissociaCon
Maybeseen
Notseen
Regularity
Slightlyirregular
Veryregular
FusionBeats
Maybeseen
Notseen
IniCalQRSdeflecCon
Maydifferfromnormal
QRScomplex
SameasnormalQRS
complex
ClinicalClues
EKGClues
VentricularArrhythmias
PVC’s
Torsadesde
Pointes
AtrialEnlargement
•  LookatPwavesinleadsIIandV1
•  Rightatrialenlargement(Ppulmonale)
–  1.IncreasedamplitudeinfirstporCon
ofPwave
–  2.NochangeinduraConofPwave
–  3.PossiblerightaxisdeviaConofPwave
•  LeVatrialenlargement(pmitrale)
–  1.Occasionally,increasedamplitudeofterminalpart
ofPwave
–  2.Moreconsistently,increasedPwaveduraCon
–  3.NosignificantaxisdeviaCon
VentricularHypertrophy
•  LookattheQRScomplexesinallleads
•  Rightventricularhypertrophy(RVH)
–  1.RAD>100°
–  2.RaCoofRwaveamplitudetoSwaveamplitude>1inV1and<1inV6
•  LeVventricularhypertrophy(LVH)
PrecordialCriteria
LimbLeadCriteria
RwaveinV5orV6+S
RwaveinaVL>13mm
waveinV1orV2>35mm
RwaveinV5>26mm
RwaveinaVF>21mm
RwaveinV6>18mm
RwaveinI>14mm
RwaveinV6>Rwavein
V5
RwaveinI+SwaveinIII
>25mm
MyocardialInfarcCon
•  Dx–Hx,PE,serialcardiacenzymes,serial
EKG’s
•  3EKGstagesofacuteMI
–  1.Twavepeaksand
theninverts
–  2.STsegmentelevates
–  3.Qwavesappear
QWaves
•  CriteriaforsignificantQwaves
–  Qwave>0.04secondsinduraCon
–  Qwavedepth>⅓heightofRwaveinsameQRS
complex
•  CriteriaforNon-QWaveMI
–  Twaveinversion
–  STsegmentdepressionpersisCng>48hoursin
appropriateclinicalse{ng
LocalizingMIonEKG
•  InferiorinfarcCon–leadsII,III,aVF
–  OVencausedbyocclusionofrightcoronaryarteryorits
descendingbranch
–  ReciprocalchangesinanteriorandleVlateralleads
•  LateralinfarcCon–leadsI,aVL,V5,V6
–  OVencausedbyocclusionofleVcircumflexartery
–  Reciprocalchangesininferiorleads
•  AnteriorinfarcCon–anyoftheprecordialleads(V1-V6)
–  OVencausedbyocclusionofleVanteriordescendingartery
–  Reciprocalchangesininferiorleads
•  PosteriorinfarcCon–reciprocalchangesinleadV1(ST
segmentdepression,tallRwave)
–  OVencausedbyocclusionofrightcoronaryartery
LocalizingMIonEKG
STsegment
•  ElevaCon
–  SeenwithevolvinginfarcCon,Prinzmetal’sangina
–  Othercauses–JpointelevaCon,apicalballooning
syndrome,acutepericardiCs,acutemyocardiCs,
hyperkalemia,pulmonaryembolism,Brugada
syndrome,hypothermia
•  Depression
–  SeenwithtypicalexerConalangina,non-QwaveMI
–  Indicatorof+stresstest
ElectrolyteAbnormaliCesonEKG
•  Hyperkalemia–peakedTwaves,prolonged
PR,flagenedPwaves,widenedQRS,merging
QRSwithTwavesintosinewave,VF
•  Hypokalemia–STdepression,flagenedT
waves,Uwaves
•  Hypocalcemia–prolongedQTinterval
•  Hypercalcemia–shortenedQTinterval
Drugs
•  Digitalis
–  TherapeuCclevels–STsegmentandTwavechanges
inleadswithtallRwaves
–  Toxiclevels–tachyarrhythmiasandconducCon
blocks;PATwithblockismostcharacterisCc.
•  MulCpledrugsassociatedwithprolongedQT
interval,Uwaves
–  Sotalol,quinidine,procainamide,disopyramide,
amiodarone,dofeClide,dronedarone,TCA’s,
erythromycin,quinolones,phenothiazines,various
anCfungals,someanChistamines,citalopram(only
prolongedQTinterval–dose-dependent)
EKG∆’sinotherCardiacCondiCons
•  PericardiCs–DiffuseSTsegmentelevaConsand
Twaveinversions;largeeffusionmaycauselow
voltageandelectricalalternans(alteringQRS
amplitudeoraxisandwanderingbaseline)
•  MyocardiCs–conducConblocks
•  HypertrophicCardiomyopathy–ventricular
hypertrophy,leVaxisdeviaCon,septalQwaves
EKG∆’sinPulmonaryDisorders
•  COPD–lowvoltage,rightaxisdeviaCon,and
poorRwaveprogression.
•  Chroniccorpulmonale–Ppulmonalewith
rightventricularhypertrophyand
repolarizaConabnormaliCes
•  Acutepulmonaryembolism–rightventricular
hypertrophywithstrain,RBBB,andS1Q3T3
(withTwaveinversion).Sinustachycardiaand
atrialfibrillaConarecommon.
EKG∆’sinOtherCondiCons
•  Hypothermia–Osbornwaves,prolonged
intervals,sinusbradycardia,slowatrial
fibrillaCon,bewareofmuscletremorarCfact
•  CNSDisease–diffuseTwaveinversionwithT
waveswideanddeep,Uwaves
•  Athlete’sHeart–sinusbradycardia,nonspecific
STsegmentandTwavechanges,RVH,LVH,
incompleteRBBB,firstdegreeorWenckebachAV
block,possiblesupraventriculararrhythmia
UgerConfusion
•  Verifyleadplacement
•  RepeatEKG
•  RepeatstandardizedprocessofEKGanalysis-
starCngoverfromthebeginningwithbasics–
rate,intervals,axis,rhythm,etc.andproceed
throughenCrestepwiseanalysis
•  ConsiderCardiologyconsultaCon
ArrhythmiaIndicaConstoConsult
Cardiology
•  DiagnosCcormanagementuncertainty
•  MedicaConsnotcontrollingsymptoms
•  PaCentisinhigh-riskoccupaConorparCcipatesin
high-riskacCviCes(pilot,scubadriving)
•  PaCentsprefersintervenConoverlong-termmeds
•  PreexcitaCon
•  Underlyingstructuralheartdisease
•  Associatedsyncopeorothersignificantsymptoms
•  WideQRS
CareConsideraConsPriorto
CardiologyConsult
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• 
ThoroughHxandPE
Basiclabs
EKGandrepeatEKG
Holtermonitor
Echocardiogram
Acuityofcarerequired–considerrisks,
hemodynamicstability
PacemakerConsideraCons
•  Third-degree(complete)AVblock
•  SymptomaCclesserdegreeAVblockor
bradycardia
•  SuddenonsetofvariouscombinaConsofAV
blockandBBBduringacuteMI
•  Recurrenttachycardiasthatcanbeoverdriven
andterminatedbypacemakers
OsteopathicConsideraCons
•  Treatments–
–  LymphaCcs–thoracicinlet,abdominaldiaphragm,
ribraising,lymphaCcpumps
–  SympatheCcs(T1-T6)–cervicalganglion,rib
raising,T1-T6,Chapman’sreflexes,T10-L2for
adrenal/kidney
–  ParasympatheCcs–OA/AA/cranial–vagusnerve
ClinicalCases/EKG’s
Case1
•  53yearoldcaucasianfemalewith4day
hxofseverecentralchestpainon
exerCon,previouslyalleviatedwithrest;
nowworsenedoverlast24hoursand
sustainedatrest
•  PMHx–DM2,HTN,hyperlipidemia
•  Appearsunwell,inpain,sweaty,andgrey
Case1
•  Diagnosis?EKGfindings?
Case1
•  AcuteanteriorST-elevaConMIwith
“tombstone”or“fireman’shat”inV1-V4
•  Tx?LocalizaCon?
Case1
•  PCIstenCngofLAD
•  Post-procedure=resolvingSTelevaCon;lossof
ominoustombstoneeffect;Qwavesdeveloping
Case2
•  45yomalepresentswithacuteSOBs/plong
vacaConinParis
•  PMHx-asthma,Crohn’sdisease,anxiety,
GERD,tobaccoabuse
•  VS37,148/92,130,26
•  PaCentappearsuncomfortablebutotherwise
unremarkableexam
Case2
•  Diagnosis?EKGfindings?
Case2
•  AcutePEwithsinustachycardia,aPVC,and
S1Q3T3pagern
Case3
•  72yomalepresentstotheofficefor
evaluaConpriortocataractsurgery
•  Nocomplaints
•  PMHx–B/Lcataracts,OA,HTN,
hyperlipidemia,andchroniclowbackpain
•  VS37.2,152/86,74,14
Case3
•  Diagnosis?EKGfindings?
Case3
•  LVH–QRSvoltagecriteriainprecordialleads
andrepolarizaConchangesinV5,V6
Case4
•  27yofemalepresentstotheEDwithc/o
chestdiscomfortandpalpitaConsaVer
studyingallnightforgraduateschoolexams
•  Appearsnervousand“uneasy”withrapid
pulse
•  PMHx–unremarkable;nomeds,admitsto
occasionalalcohol,non-smoker,deniesillicit
druguse,usedcoffeetostayawaketostudy
Case4
•  Diagnosis?EKGfindings?
Case4
•  SVT–regular,narrow-QRStachycardia,rateof
160bpm
Case5
•  46yomalepresentstoEDwithc/osevereHA
persisCngover5hoursdespite
acetaminophenandNSAIDagemptsas
aborCvetherapy
•  PMHx–occasionalleVshoulderpain,nonsmoker
•  ConstrucConworker
•  VSS;unremarkableexam
Case5
•  Diagnosis?EKGfindings?
Case5
•  NormalEKG
Case6
•  56yofemalepresentstofamilyphysicianwith
c/olight-headednessandoccasionalflugerin
herchest
•  PMHx–anxiety,depression,obesity,smoker
•  Worksasretailstoremanager
•  VSS;coursebreathsounds,otherwise
unremarkableexam
Case6
•  Diagnosis?EKGfindings?
Case6
•  SeconddegreeAVblock–MobitzTypeI–
Wenckebach(specifically3:2AVWenckebach
phenomenonwhereevery3rdPwaveis
blocked)
Case7
•  28yomalepresentsforcommercialdriver’s
license(CDL)evaluaCon
•  Nocomplaints
•  VSS;asymptomaCc;examwithoutsignificant
findings
Case7
•  Diagnosis?EKGfindings?
Case7
•  TypicalpreexcitaCon(WPW)pagern
•  ShortPRintervalanddeltawavesinmany
leads
•  TxiscloseobservaConunlesspaCenthashad
SVToratrialfibrillaConwhichindicatestxwith
ablaConofaccessorypathway
Case8
•  32yomalepresentstoEDwithc/ofeelingsick
forthelast6days
•  Symptomsincludefevers,cough,anddifficulty
catchinghisbreath
•  PMHx–hyperlipidemia,obesity,metabolic
syndrome
•  VS38.1,105,128/84,22
Case8
•  Diagnosis?EKGfindings?
Case8
•  AcutepericardiCs–diffuseSTelevaConwith
PRsegmentdepressionisdiagnosCc
Case9
•  67yomalepresentstohiscardiologistforoutpaCent6weekpost-hospitalvisit
•  PrevioushospitalizaConfornon-cardiacchest
pain
•  Post-hospitalcardiacmeds–ACEinhibitor,
betablocker,aspirin,nitrate
•  Nocurrentcomplaints
Case9
•  Diagnosis?EKGfindings?
Case9
•  AtrialfibrillaCon–irregularlyirregularwithout
Pwaves
•  RBBB–wideQRSwithrsR’pagerninV1,
broadSwavesinleadsIandaVL
•  Inferiorinfarct–non-acute(>1week)
pathologicQwavesininferiorleads(II,III,and
aVF)
Case10
•  79yomalebroughttoEDviaEMSwithchest
pain,SOB,andnear-syncope
•  PMHx–unobtainablesecondarytopaCent
distress
•  VS–36.9,140’s,82/40,28
Case10
•  Diagnosis?EKGfindings?
Case10
•  Monomorphicsustainedventricular
tachycardia(VT)–couldrapidlydeteriorate
intoVF,torsadesdepointes,asystole,or
suddendeath
Case11
•  82yofemaleadmigedtoacutecarehospital
secondarytochestpain
•  PMHx–HTN,DM2,CHF,obesity,depression
•  CardiologyplanningcardiaccatheterizaCon
secondarytonewfindingduringiniCal
consultaCon
Case11
•  Diagnosis?EKGfindings?
Case11
•  LBBB–wideQRS;broad,notchedRwavein
V5,V6andIwithSTdepressionandTwave
inversion
Case12
•  59yomalepresentstoEDdiaphoreCcandin
distress
•  PMHx–HTN,ESRD,DM2,LeVBKA
•  VS–37.5,108,96/58,24
Case12
•  Diagnosis?EKGfindings?
Case12
•  Hyperkalemia–tallpeakedTwavespresent
throughout;otherprogressiveEKGchanges
mayfollowwithincreasingpotassiumlevels–
prolongedPRinterval,flagenedPwaves,
wideningQRS,sinewaves
•  Sinustachycardiaalsopresent
BonusCase
•  18yomaleundergoingmilitaryphysicalexam
andevaluaConpriortobootcamp
•  Nocomplaints
•  PMHx–denies
•  VSS;examunremarkable
BonusCase
•  Diagnosis?EKGfindings?
BonusCase
•  Reversedarmleads–invertedPwavesin
leadIwithnormalRwaveprogressionin
precordialleads
BoardExamPoints
•  EKG’slikelytohave1mainfinding
•  ClinicalcaselikelyincludedwitheachEKG
•  QuesConlikelytofocusonclinicalcaseaswellas
EKG
•  Straightforwardwithouttricksorobscurefindings
(notlikelytosee“zebras”)
•  Focusoncommonarrhythmias,commoncardiac
diagnoses,commonnon-cardiacEKGabnormaliCes,
oremergent“can’tmiss”diagnoses
QuesCons?
Resources
•  SourcesandSuggestedReferences
–  TheOnlyEKGBookYou’llEverNeed-MalcolmS.Thaler
–  RapidInterpretaConofEKG’s–DaleDubin,M.D.
–  “…ExceptforOMT!”–DalePrag-Harrington
–  AmericanFamilyPhysician–November1,2015
–  UptoDate
–  blogatwordpress.com
–  cme.umn.edu
–  ekgcasestudies.com
–  healio.com
–  lifeinthefastlane.com
–  learntheheart.com