Post on 24-Mar-2020
09/10/2014
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ECG Workshop
Dr. Ross MacKenzie FRCPC FACC 2014 AAIM Annual Meeting – Philadelphia
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ECG Workshop
Objectives:
• Uncommon ECG patterns with high mortality implications
• Common ECG underwriting challenges
• Focus on ECG morphology
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09/10/2014
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3
55-
45-
35-
25-
15-
5-
-5-
20 30 40 50 60
The Life Insurance Risk Corridor
Deaths per
1000
500%
Standard
50
Age
Mortality Ratio
0 2 4 6 8 10 12 14 16
180
160
140
1 20
100
80
60
40
20
Major abnormality
Men
Women
Major abnormality
Normal
Normal
Mortality per 1000
YearsMajor ECG Abnormalities and Mortality
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0 2 4 6 8 10 12 14 16
140
120
100
80
60
40
20
Minor abnormality
Men
Women
Minor abnormality
Normal
Normal
Years
Mortality/1000
Minor ECG Abnormalities and Mortality
39 year old life insurance medical director
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7
Asymptomatic 39 year old male
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Asymptomatic 51 year old male
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49 year old asymptomatic male
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Asymptomatic 40 year old male
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38-year old stockbroker – ECG for “age and amount”
Courtesy of Dr. M. Clark
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ECG from 5 years prior to the application
Courtesy of Dr. M. Clark
09/10/2014
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13
Normal R wave Progression - Horizontal Vector Loop
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Anteroseptal Infarction
Horizontal Plane
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Technical errors recording the chest leads - the P wave in V2
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Changing P-Wave Morphology in Lead V2
Ilg KJ, et al, Am J Med 2012; 125:23.
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Right ventricular hypertrophy and COPD
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55 year old asymptomatic woman who is an ex-smoker
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22 year old professional soccer player
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62 y.o. woman with long history of mild hypertension
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Left Ventricular Hypertrophy
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51 year old male with 10 year history of well-controlled hypertension
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Left Ventricular Hypertrophy
Horizontal Plane
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25 year old asymptomatic male
Brugada ECG PatternsBrugada ECG PatternsBrugada ECG PatternsBrugada ECG Patterns
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Diagnostic Criteria for Brugada Diagnostic Criteria for Brugada Diagnostic Criteria for Brugada Diagnostic Criteria for Brugada SyndomeSyndomeSyndomeSyndome
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
MeregalliMeregalliMeregalliMeregalli P G et al. P G et al. P G et al. P G et al. CardiovascCardiovascCardiovascCardiovasc Res 2005;67:367Res 2005;67:367Res 2005;67:367Res 2005;67:367----378378378378 28
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ECG during flecainide provocation test showing marked increase in ST segment elevation in leads V1–V3.
36 year old asymptomatic male college basketball coach
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26 year old asymptomatic male
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Normal Precordial ST Segment ElevationNormal Precordial ST Segment ElevationNormal Precordial ST Segment ElevationNormal Precordial ST Segment Elevation
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Is Early Repolarization Still Benign ?Is Early Repolarization Still Benign ?Is Early Repolarization Still Benign ?Is Early Repolarization Still Benign ?
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51 y.o. asym. male with diabetes
41 year old asymptomatic female
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21 year old asymptomatic male
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32 year old asymptomatic female
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Prevalence 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; 95:1070Aro AL. Circulation 2012; 125:1272
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25 year old asymptomatic male
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33 year old asymptomatic female
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Complete Heart Block
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24 year old female marathon runner
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Isorhythmic AV Dissociation
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49 year old asym. physically active male college professor
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2:1 AV Block
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49 year old asym.physically active male college professor
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Mobitz Type 1 (Wenckebach) Second Degree AV Block
Mobitz Type 2 Second Degree AV Block
09/10/2014
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21 year old female with history of seizures
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QTcQTcQTcQTc ScaleScaleScaleScale
T Wave Changes in Long QT SyndromeT Wave Changes in Long QT SyndromeT Wave Changes in Long QT SyndromeT Wave Changes in Long QT Syndrome
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Sudden Death in DalmatiansSudden Death in DalmatiansSudden Death in DalmatiansSudden Death in Dalmatians
Normal QTNormal QTNormal QTNormal QT Long QTLong QTLong QTLong QT
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