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Transcript of 12-Lead EKG Interpretation - Oregon Society of Physician …oregonpa.org/resources/2015CME/Speaker...
10/22/2015
1
Jon Tardiff, BS, PA-C
OHSU Clinical Assistant Professor
12-Lead EKG [email protected]
• I work for Virginia Garcia
Memorial Health Center,
Beaverton, Oregon.
• And I am a medical editor for Jones & Bartlett Publishing.
Disclosures:
Arabic, Somali, Mai Mai, Pashtu, Urdu, ASL, and more!
11 clinics: 39,000 patients from all over the World!
10/22/2015
2
4
Goals for today’s ECG Review:
• Determine Right vs Left bundle branch blocks
• Determine Axis
• Diagnose Acute MI
• Diagnose old MI
• Location of the infarct
• Other Acute Coronary Syndromes
• Life Threatening Syndromes
“Ask questions!” ☺☺☺☺
Ready?
What a 12-Lead EKG can help you do
• Diagnose ACS / AMI
• Interpret arrhythmias (computer Dx)
• Identify life-threatening syndromes (WPW, LGL, Long QT synd., Wellens synd., etc)
• Infer electrolyte imbalances
• Infer hypertrophy of any chamber
• Infer COPD, pericarditis, drug effects, and more!
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7
For example:
73 y.o. male with nausea, syncope
8
Acute Inferior MI
ST elevation
What rhythm? (look at V1 for P waves)
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Atrial flutter (w/septal MI?)
The flutter waves are invisible in Lead II
11
another example…
12
WPW with Atrial Fib
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WPW Graphic
Wolff-Parkinson-White synd.
• short PR
• wide QRS
• delta wave
14
Same pt, converted to SR
Limitations of a 12-Lead ECG
• Truly useful only ~40% of the time
• Each ECG is only a 10 sec. snapshot
• Serial ECGs are necessary, especially for ACS
• Other labs help corroborate ECG findings (cardiac markers, Cx X-ray)
• Confounders must be ruled out (dissecting aneurysm, pericarditis, WPW, LBBB, digoxin, RVH)
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16
Confounder: Left Bundle Branch Block
Limitations of a 12-Lead ECG
• The ECG is occasionally wrong!
18
Impending AMI with normal ECG!
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19
13 hrs later — Acute Anterior MI
Elevated ST segments
Pt is a 4 y.o. child w/ one episode of tachycardia
and shortness of breath.
WPW mimicking MI (false Q waves in Lead II, III,
AVF, V1, & V3). Also mimicking LBBB.
Confounder: Wolff-Parkinson-White syndrome
“ECG Pearls”
• Lead II is the easiest lead to read / most intuitive
• But Lead V1 is our single best lead.
• Use Lead V3 for QT interval measurement
• “A Q in III is free.” (isolated Q in Lead III)
• Half of reading an ECG is knowing
where the + electrode is.
• The other 80% is: finding the P wave!
☺
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22
ECG Lead Placement
&
Electrophysiology Review
23
Einthoven’s Triangle
� I
� II
� III
Limb Leads
(standard
leads)
- ±
+
24
Leads I, II, III
I
II III
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9
Normal 12-Lead ECG
26
Rapid Interpretation Tips
The first EKG machine ca 1903
Dr. Willem Einthoven
Dr. Willem Einthoven
• Invented the electrocardiograph
• Discovered atrial fibrillation
• Won Nobel Prize for Medicine 1924
10/22/2015
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2828SA Node AV Node His Bundle BBs Purkinje Fibers
P
Q
R
S
T
II
U
Conduction System
29Q
R
S
P wave axis
R wave axis
…upright in L II
…upright in L II
Lead II
30
QRS Morphology in Lead II
II
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11
3131
PR
II
Intervals
PR Interval: 120 – 200 mSec (3 – 5 boxes)
QRS width: 60 – 120 mSec (1½ – 3 boxes)
QT/QTc interval: 400 mSec (10 boxes)
QTQRS
32
Heart Rate Calculations
� 300, 150, 100,
� 75, 60, 50
� Quick, easy, sufficient
Triplicate Method:
� Count PQRST in a 6-
second strip & multiply x 10
� Easy, & more accurate
6-second :
300 150 100 75 60 6 seconds
Horizontal axis is time (mS); vertical axis is electrical energy (mV)
33
Normal Sinus Rhythm
� What is the heart rate?
6 seconds
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34
EKG Leads
� I
� II
� III
� aVR
� aVL
� aVF
Limb (frontal plane) Leads
(augmented leads)
(standard
leads)
Normal 12-Lead ECG
36
6 Frontal Plane Leads (limb leads)
I
II III
R
L
F
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13
Axis
37
Leads I
II
III
aVR*
aVL
aVF
-
38
“Knowing where the + electrode is”
39
EKG Leads
� I
� II
� III
� aVR
� aVL
� aVF
� V1
� V2
� V3
� V4
� V5
� V6
Limb (frontal
plane) Leads
(augmented leads)
(standard
leads)(anterior
leads)
(lateral
leads)
Chest (precordial)
Leads
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40
V Lead Cutaway
V Lead Progression
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15
Normal 12-Lead ECG
Lots of ways to read EKGs…
• QRSs wide or narrow?
• Regular or irregular?
• Fast or slow?
• P waves?
• Sinus rhythm or not?
• If not, is it atrial fibrillation?
• BBB?
• MI?
Symptoms:
• Syncope is bradycardia, heart blocks, or VT
• Rapid heart beat is AF, SVT, or VT
45
Step-by-step method for reading a 12-Lead
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16
Rapid Interpretation Tips
Rapid Interpretation Tips
• Identify the rhythm. If supraventricular*,
If no LBBB,
If present,
• Rule out other confounders: WPW, pericarditis, LVH,
digoxin effect
• Identify location of infarct, and consider appropriate
treatments: MONA, PCI [or fibrinolytic], nitrate
infusion, heparin infusion, GP IIb, IIIa inhibitor, beta-
blocker, clopidogrel, statin, etc.
Supraventricular rhythms
• Sinus rhythm
• Atrial fibrillation
• Junctional rhythm
• PSVT / AVNRT (AV nodal re-entry tachycardia)
• Atrial tachycardia
• Atrial flutter
• Wandering atrial pacemaker
• MAT
Normal 12-Lead ECG
10/22/2015
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Rapid Interpretation Tips
Rapid Interpretation Tips
• Identify the rhythm. If supraventricular,
If no LBBB,
If present,
• Rule out other confounders: WPW, pericarditis, LVH,
digoxin effect
• Identify location of infarct, and consider appropriate
treatments: MONA, PCI [or fibrinolytic], nitrate
infusion, heparin infusion, GP IIb, IIIa inhibitor, beta-
blocker, clopidogrel, statin, etc.
The Problem with Bundle
Branch Blocks
• Desynchronized contraction of the ventricles
• Reduced cardiac output
• Worsened heart failure
• LBBB confounds the EKG interpretation
and makes it harder to find ACS
51
Bundle Branch Blocks(QRS > 0.12 sec.)
Left BBB(L I, V5, V6:
upright QRS
with a notch)
Right BBB(V1, V2, MCL1:
rsR’ pattern)
R’
S
r
notchIV1
(left-sided lead)(right-sided lead)
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18
52
Bundle Branch Blocks:Two QRSs
notchI
Healthy
ventricle
Blocked
bundle
R’
S
r
V1 slurI
V1 & V2
RBBB
V5 V6
(& I, aVL)
LBBB
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55
Practice: Bundle Branch Block
RBBB
Which Bundle Branch is Blocked? 1
RBBB
Right Bundle Branch Block (Lead V1) 1
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LBBB 12-Lead
Which Bundle Branch is Blocked? 2
LBBB 12-LeadLeft Bundle Branch Block(L I, V5, V6)
2
Where is the Pathology?
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21
Right Bundle Branch Block
62
Where is the Pathology?
63
Left Bundle Branch Block
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Axis Determination
65
Why We Care About Axis Deviations
The axis shifts towards hypertrophy
& away from infarction
66
Axis Deviation
Horizontal heart (0°): obesity,
3rd trimester pregnancy. Ascites
Vertical heart (90°): slender build
Left Axis Deviation: LBBB,
Anterior MI, Inferior MI, Left
anterior hemiblock, LVH
Right Axis Deviation: Anterior
MI, Lateral MI, RBBB, COPD,
RVH, Left posterior hemiblock
Extreme RAD: Ectopic rhythm
(VT), massive MI
Normal axis = -20° to +110°
10/22/2015
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How to calculate Axis
Easiest: the computer does it for you!
Easy: find the tallest R wave
(if tallest is Lead II = normal axis)
Even easier: (if Lead II is upright =
normal axis
Funnest: Thumbs up / Thumbs down
68
Calculating Axis: Thumbs Up / Down Method
Lead I —Your Left thumb
Lead aVF —Your Right thumb
69
Practice: Axis 3
I
F
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70
Axis Practice Normal Axis
I
F
3
71
4
I
F
72
4
Left Axis Deviation
I
F
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73
5
74
5
Right Axis Deviation
75
6
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76
6
Extreme Right Axis Deviation
77
New 12-Lead ECG Format
aVL
I
-aVR
II
aVF
III
New 12-Lead ECG Format
aVL
I
-aVR
II
aVF
III
New
Old
10/22/2015
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Rapid Interpretation Tips
Rapid Interpretation Tips
• Identify the rhythm. If supraventricular,
• Rule out left bundle branch block. If no LBBB,
• Check for: ST elevation, or ST depression with T
wave inversion, and/or pathologic Q waves.
If present,
• Rule out other confounders: WPW, pericarditis, LVH,
digoxin effect
• Identify location of infarct, and consider appropriate
treatments: MONA, PCI [or fibrinolytic], nitrate
infusion, heparin infusion, GP IIb, IIIa inhibitor, beta-
blocker, clopidogrel, statin, etc.
Ischemia Injury InfarctionNormal
STEMI
ST elevation, ST depression, T wave inversion,
pathologic Q waves
81
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Percutaneous Coronary Intervention
84
RCA before and after stenting
Before stenting After stenting
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STEMI: ECG Changes
A. Normal ECG
B. Hyperacute T wave changes -
increased T wave amplitude and
width; may also see ST elevation
C. Marked ST elevation with
hyperacute T wave changes
(transmural injury)
D. Pathologic Q waves, less ST
elevation, terminal T wave
inversion (necrosis)
E. Pathologic Q waves, T wave
inversion (necrosis and fibrosis)
F. Pathologic Q waves, loss of R
waves (fibrosis)
(w/onset cx pn)
(20 minutes) (1 hour)
(1 week – years)(>1 hr)
(normal)
MI ECG Patterns
87
Why Pathologic Q Waves Form
Normal q Pathologic Q
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88
STEMI — Typical Progression
Acute Inferior MI#1
Acute Inferior MI
ST elevation
Qs Qs
Axis is shifting
leftward…
Acute Inferior MI #2
Same Patient~2 hrs later
Worsened ST elevation
Qs Qs
New ST elevation
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Acute Inferior MI #3Same Patient 9 days later
Permanent Q waves
(inferior wall scar)
But NO anterior infarct (no Qs)
Permanent left axis
deviation
Acute Anterior MI Page
45% of MIs
Acute Inferior MI Page
40% of MIs
10/22/2015
32
Acute R Ventricle MI Page
1/3 of Inferior MIs
Acute Lateral MI Page
15% of MIs
Acute Posterior MI Page
10/22/2015
33
97
Practice: Infarct Location
Acute Anterior MI
Where is the Pathology?7
Acute Anterior MI(ST elevation in V1 - V4)
ST Elevation
What is the R wave axis?
7
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Acute Inferior MI
Where is the Pathology? 8
Acute Inferior MIAcute Inferior MI
(ST elevation in II, III, F)
8
Acute Inferolateral MI
Where is the Pathology? 9
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Acute Inferolateral MIAcute Inferolateral MI(ST elevation in II, III, F, V5, V6)
Note the axis has not shifted yet, because it is early in the AMI,
and there are no loss of R waves yet.
9
Where is the Pathology? 10
Acute Inferior & Right Ventricle MI
Acute Inferior MI & Right Ventricle MI10
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Where is the MI?
Normal V1 – V3
• V1, V2, V3
• Large R Waves
• Depressed STsST Depression
Large R waves
11
Acute Posterior MI
Normal V1 – V3
• V1, V2, V3
• Large R Waves
• Depressed STsST Depression
Large R waves
11
108
Time for a Break!
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109
Jon Tardiff, BS, PA-C
EKG: Life-Threatening Syndromes
Clinical Assistant Professor
110
Goals of this session:
Identify:
• WPW (Wolff-Parkinson-White) syndrome
• LGL (Lown-Ganong-Levine) syndrome
• Brugada syndrome
• Long QT syndrome
• Wellens syndrome
What a 12-Lead EKG can help you do
• Diagnose ACS / AMI
• Interpret arrhythmias
• Identify life-threatening syndromes (WPW, LGL, Long QT synd., Wellens’ synd., etc)
• Infer electrolyte imbalances
• Infer hypertrophy of any chamber
• Infer COPD, pericarditis, drug effects, and more!
10/22/2015
38
Top 10 Causes of Death In USA~ 2,000,000 deaths / year
*
* if you are < 55 y.o., trauma is your most likely risk!
Not shown are
deaths due to
medical errors:
~50,000 – 100,000 /
year!
Pacemaker Lead Reversal in a
Dual-Chamber Pacemaker
yikes!
Wolff-Parkinson-White Syndrome
• Short PR Interval • Wide QRS • “Delta” wave in some leads
• Causes tachycardias • Mimicks MI, BBB
• Pt is at-risk for sudden death (“R on T”; atrial fibrillation)
• Incidence may be 1/1000
Drs. Wolff,
Parkinson,
and White
c. 1930
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39
WPW Graphic
Wolff-Parkinson-White syndrome
(Bundle
of Kent)
WPW-Adensoine Conversion
WPW pattern
Orthodromic
(normal)
conduction
Antidromic
(retrograde)
conduction
PSVT
Valsalva
Adenosine
NSR
Drs. Wolff, Parkinson, & White
Dr. Louis Wolff
• Chief of
Electrocardiology
• CAD, unstable angina
• Vectorcardiology
• Concert violinist
Dr. Paul Dudley White
• The “Father of American
Cardiology”
• Helped found the AHA
• Promoted low cholesterol
diet, normal body weight,
normal BP, exercise,
cardiac rehab
• Advocate for World Peace
Sir John Parkinson, MD
• Founded modern British cardiology
• Pioneer in radiocardiology
• Beloved Teacher
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40
WPW mimicking VTAF with WPW—rapid ventricular rate!
• Cardiovert, or Amiodarone
Defibrillate!
A-Fib with WPW degenerating to V-Fib
Pad / Paddle Placement
For:
• pacing
• defibrillation
• synchronized cardioversion
For conscious V-Tach, and SVT.
Synchronized shock delivers
energy synchronized to the R
wave.
However, for V-Fib and
unconscious V-Tach, defibrillate
instead with unsynchronized
shock.
Synchronized Cardioversion
10/22/2015
41
Lown-Ganong-Levine syndrome
• A “Short PR Syndrome”
• Normal QRS (NOT wide) • No “Delta” wave
• Must also have episodes of tachycardia in order to be called
LGL syndrome. (Otherwise it’s just a short PR interval.)
Dr. Lown Dr. Ganong Dr. Levine
Lown-Ganong-Levine
syndrome
• Accessory pathway bypasses
AV node—inserts into His bundle
• This shortens the PR interval
• But the QRS is normal (NOT wide)
• and there is No “Delta” wave
• May have reciprocating tachycardias
Short PR
James fibers
Drs. Lown, Ganong, & Levine
Dr. Bernard Lown• Developer of the
defibrillator
• Coronary Care Units
• Physicians for Social
Responsibility
• Nobel Peace Prize
• Single payer healthcare
(Mass.)
• The Lown Institute
Dr. William Ganong• Electrophysiologist
• Neuroendocrinologist
• Fluid, electrolytes, HTN
• Author: Review of Medical
Physiology
Dr. Samuel Levine• Levine Grading Scale for
heart murmurs (I/VI)
• “Levine Sign” for ACS
• Coronary thrombosis
• Pernicious anemia
• Diagnosed FDR with polio
• Always on call!
10/22/2015
42
LGL (48 y.o. F) LGL?
Short PR
But QRS is narrow,
and NO delta wave
Brugada Syndrome(a “channelopathy”)
• Sodium channel defect
(the QRS is a sodium event)
• RBBB on EKG, with ST
elevation in V1 - V3
• SUDS (Sudden Unexplained
Death Syndrome)
• 10% of these patients die / year
• ICD is life-saving
Dr. Pedro Brugada
Brugada Syndrome
• The QRS is a sodium event
Q S
R
10/22/2015
43
Absolute
Refractory
Period
Relative Refractory
Period
(vulnerable period)
Polymorphic VT
in patients with Brugada Syndrome
“R on T” (a PVC on the T wave) causes VT & sudden death
R on T
“R on T”Torsades de Pointes
Ventricular Fibrillation
“R on T” phenomenon(PVC on T wave: precipitating V-Tach)
(polymorphic V-Tach)
10/22/2015
44
Long QT Syndrome
• QTc Interval > 450 ms (>470 ms ) (normal QTc is 400 ms)
• Several inherited forms, plus temporary, & iatrogenic causes
• Incidence may be 1/5000 • A possible cause for SIDS
• Patient is at risk for sudden death from R on T, Torsades de Pointes
• Beta blockers are therapeutic, along with limiting physical activity
• Implanted cardioverter / defibrillator (ICD) is life-saving
Torsades de pointes
(polymorphic V-Tach)
131
II
QT Interval
QT/QTc interval: 400 mSec (10 boxes)
Or: less than ½ the R-R interval
QT
Long QT
QT should be <½ the R-R interval
R R
Long QT Syndrome(use Lead V3, or V4, or the longest QT interval on the 12-Lead)
10/22/2015
45
• Obstetrician
• Secret Agent
• Supercop
• Author: Solving Conflict With Dialog
龙曲提医生Dr. Lóng Qú Ti
Jackie Chan
• Martial artist
• Actor, Singer
• Producer, director
• 100 films
• Beloved father,
husband
• Great philanthropist!
成龙先生
Long QT Syndrome
• Patient is at risk for sudden death from R on T, polymorphic VT
• Implanted cardioverter / defibrillator (ICD) is life-saving
Torsades de pointes
(polymorphic V-Tach)
10/22/2015
46
ICD Shocking V-Tach
ICD is life-
saving for
patients with
Long QT
syndrome
Iatrogenic Long QT
Question:
What are the Top 3 causes of arrhythmias?
138
The “Top 3” Causes of Arrhythmias:
1. Medications
2. Medications
3. Medications
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47
139
Meds that prolong the QT interval
Here they are!
Albuterol (salbutamol)
Alfuzosin
Amantadine
Amiodarone
Amitriptyline
Amphetamine
Anagrelide
Apomorphine
Arformoterol
Aripiprazole
Arsenic trioxide
Artenimol+piperaquine
Atazanavir
Atomoxetine
Azithromycin
Bedaquiline
Bortezomib
Bosutinib
140
Meds that prolong the QT interval
141
Ephedrine
Epinephrine (Adrenaline)
Eribulin mesylate
Erythromycin
Escitalopram
Famotidine
Felbamate
Fingolimod
Flecainide
Fluconazole
Fluoxetine
Formoterol
Foscarnet
Furosemide (Frusemide)
Galantamine
Gemifloxacin
Granisetron
Halofantrine
Haloperidol
Hydrochlorothiazide
Hydroxychloroquine
Hydroxyzine
Ibutilide
Iloperidone
Imipramine (melipramine)
Indapamide
Isoproterenol
Isradipine
Itraconazole
Meds that prolong the QT interval
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48
142
Ketoconazole
Lapatinib
Leuprolide (Leuprorelin)
Levalbuterol (levsalbutamol)
Levofloxacin
Lisdexamfetamine
Lithium
Metaproterenol
Methadone
Methamphetamine (methamfetamine)
Methylphenidate
Metoclopramide
Metronidazole
Midodrine
Mifepristone
Mirabegron
Mirtazapine
Moexipril/HCTZ
Moxifloxacin
Nelfinavir
Nicardipine
Nilotinib
Norepinephrine (noradrenaline)
Norfloxacin
Nortriptyline
Ofloxacin
Olanzapine
Ondansetron
Oxytocin
Meds that prolong the QT interval
143
Paliperidone
Panobinostat
Pantoprazole
Paroxetine
Pasireotide
Pazopanib
Pentamidine
Perflutren lipid microspheres
Phentermine
Phenylephrine
Phenylpropanolamine
Pimozide
Posaconazole
Procainamide (Oral off US mkt)
Promethazine
Propofol
Pseudoephedrine
Quetiapine
Quinidine
Quinine sulfate
Ranolazine
Rilpivirine
Risperidone
Ritonavir
Salmeterol
Saquinavir
Sertraline
Sevoflurane
Solifenacin
Meds that prolong the QT interval
144
Tacrolimus
Tamoxifen
Telaprevir
Telavancin
Telithromycin
Terbutaline
Tetrabenazine (Orphan drug in US)
Thioridazine
Tizanidine
Tolterodine
Toremifene
Torsemide (Torasemide)
Trazodone
Trimethoprim-Sulfamethoxazole
Trimipramine
Vandetanib
Vardenafil
Vemurafenib
Venlafaxine
Voriconazole
Vorinostat
Ziprasidone
159 medications!
Meds that prolong the QT interval
10/22/2015
49
145
Treatment for Long QT interval
1. Reduce the medications that are causing it.
2. Change the medications that are causing it.
3. Stop the medications that are causing it!
Wellens’ Syndrome
• Small terminal inversion of the T wave in V1, V2, V3
Dr. Hein Wellens
Wellens’ Syndrome
Dr. Hein Wellens
• Recent Hx of chest pain or anginalequivalents.
• The patient may be pain-free during the exam and while the ECG is being acquired.
• Cardiac markers may be normal.
10/22/2015
50
Wellens’ Syndrome (a broader definition)
• Inverted T waves in V1, V2, V3. No loss of R waves, No Qs.
Imminent catastrophe
—Yikes!
Significance of Wellens’ Syndrome
Significance of Wellens’ Syndrome
• 75% chance of massive anterior MI
• Proximal LAD lesion; (50% of LV)
• The patient should be referred to
angiography quickly for PCI (or CABG)
to prevent the MI.
• Stress test is fatal!
10/22/2015
51
95% occlusion of the proximal LAD
Percutaneous Coronary Intervention
Artery before stenting
(red is lumen; yellow is obstruction)After stenting
Note the much larger lumen
The Spectrum of Acute Coronary Syndromes
Healthy CAD Angina Unstable Angina NSTEMI STEMIShock /
Death
Patent
artery
~50% ~70% >70% or 100% ~90% 100% 100%
(or vasospasm)
No symptoms Pain on
exertion
Pain at rest;
relieved by NTG Constant pain
10/22/2015
52
Wrap it Up!
Review!WPW: • short PR • wide QRS • Delta waves
• tachycardias • AF = sudden death
LGL: • short PR • normal QRS • NO Delta
waves • tachycardias
Brugada: • elevated STs in V1, V2, V3
• RBBB pattern • at risk for VT / VF
Long QT: • QTc > 450 (470 ) ms
• at risk for R on T = VT / VF
Wellens: • terminal T wave inversion in
V1, V2, V3 • impending massive MI
Case report:
44 y.o. male comedian
c/o episodes of rapid
heart beat. Comes to
your office for exam.
10/22/2015
53
What is the Syndrome? 12
HIPPA note:
this is not
Richard Pryor’s
actual ECG.
WPW
short PR
Wide QRS
Delta waves
12But he did
have WPW.
What is the syndrome?
30 y.o. male with episodes of rapid heart beat13
10/22/2015
54
13LGL (short PR, normal QRS, no Delta wave)
short PR
Narrow QRSs
35 y.o. male c/o episodes of rapid heart beat.
Father died @ 30 y.o., sudden death. 14
Brugada Syndrome 14
RBBB, Elevated STs
10/22/2015
55
What is the Syndrome?(extra points for the arrhythmia!)
15
Long QT interval
15
(Wenckebach) 2nd°°°° AV Block, Type I
Dr. Karel Wenckebach
Quiz- Wellens’ syndrome
What is the Syndrome? 16Chest pains on and off x 2 weeks. But no pain right now.
10/22/2015
56
Quiz- Wellens’ syndrome
Wellens’ Syndrome 16
terminal T wave inversion in V1, V2, V3
Case report:
58 y.o. male c/o chest
“tightness” and shortness
of breath x 20 minutes,
which gradually subsided.
Recurrent episodes over
several months. Pt thought
it was “acid reflux”, but
finally goes to ED. Pt is
noncompliant with statin
therapy, & admits to poor
diet. Family Hx cardiac
disease. Hx HTN. Meds:
Plavix, ACE inhibitor.
EKG follows. What treatment?
Angiography reveals 90% occlusion in some coronary arteries.
HIPPA note:
this is not
Bill Clinton’s
actual ECG!
10/22/2015
57
Treatment: quadruple CABG (coronary artery bypass graft).
Ischemia / Impending MI
no loss of R waves yet…
…but inverted T waves
But he did
have CABG
& became
adherent to
his meds…
Excellent outcome:
Pt is active, healthy, has
improved diet, is compliant
with meds.
He inspired thousands of
Americans to go to their
provider for cardiac
evaluations…
“The Bill Clinton Effect”
171
The benefits of a heart transplant