Cardiology/EKG Board Review · PDF fileCardiology/EKG Board Review Michael J. Bradley D.O....
Transcript of Cardiology/EKG Board Review · PDF fileCardiology/EKG Board Review Michael J. Bradley D.O....
Cardiology/EKGBoardReviewMichaelJ.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–makesurepaperandpaperspeedisstandardized
– 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’llEverNeedMalcolmS.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,narrowQRScomplexes,1Pwavetoevery1QRScomplex,andregularrhythm
TypesofArrhythmias
• 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;atriaandventriclesaredrivenbyindividualpacemakers
BundleBranchBlocks
• DiagnosedbylookingatwidthandconfiguraConofQRScomplexes
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
• DiagnosedbylookingatrightorleVaxisdeviaCon
• LeVAnteriorHemiblock– 1.NormalQRSduraConandnoSTsegmentorTwavechanges– 2.LeVaxisdeviaCongreaterthan-30°– 3.NoothercauseofleVaxisdeviaConispresent
• LeVPosteriorHemiblock– 1.NormalQRSduraConandnoSTsegmentorTwavechanges– 2.RightaxisdeviaCon– 3.NoothercauseofrightaxisdeviaConispresent
BifascicularBlock
• RBBBwithLAH– RBBB–QRS>0.12secandRSR’inV1andV2withLAH–leVaxisdeviaCon
• RBBBwithLPH– RBBB–RS>0.12secandRSR’inV1andV2withLPH–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;atrialrate350to500bpm;variableventricularrate;caroCdmassage:mayslowventricularrate
• MulCfocalatrialtachycardia(MAT)–irregular;atleast3differentPwavemorphologies;rate–usually100to200bpm;someCmes<100bpm;caroCdmassage:noeffect
• PAT–regular;100to200bpm;characterisCcwarm-upperiodintheautomaCcform;caroCdmassage:noeffect,ormildslowing
SupraventricularArrhythmias
RulesofAberrancyVentricularTachycardia Paroxysmal
supraventricularTachycardia
ClinicalCluesClinicalHistory Diseasedheart Usuallynormalheart
CaroCdMassage Noresponse Mayterminate
CannonAWaves Maybepresent Notseen
EKGCluesAVDissociaCon Maybeseen Notseen
Regularity Slightlyirregular Veryregular
FusionBeats Maybeseen Notseen
IniCalQRSdeflecCon MaydifferfromnormalQRScomplex
SameasnormalQRScomplex
VentricularArrhythmias
TorsadesdePointes
PVC’s
AtrialEnlargement• LookatPwavesinleadsIIandV1• Rightatrialenlargement(Ppulmonale)– 1.IncreasedamplitudeinfirstporConofPwave– 2.NochangeinduraConofPwave– 3.PossiblerightaxisdeviaConofPwave
• LeVatrialenlargement(pmitrale)– 1.Occasionally,increasedamplitudeofterminalpartofPwave
– 2.Moreconsistently,increasedPwaveduraCon– 3.NosignificantaxisdeviaCon
VentricularHypertrophy• LookattheQRScomplexesinallleads• Rightventricularhypertrophy(RVH)
– 1.RAD>100°– 2.RaCoofRwaveamplitudetoSwaveamplitude>1inV1and<1inV6
• LeVventricularhypertrophy(LVH)
PrecordialCriteria LimbLeadCriteriaRwaveinV5orV6+SwaveinV1orV2>35mm
RwaveinaVL>13mm
RwaveinV5>26mm RwaveinaVF>21mm
RwaveinV6>18mm RwaveinI>14mm
RwaveinV6>RwaveinV5
RwaveinI+SwaveinIII>25mm
MyocardialInfarcCon
• Dx–Hx,PE,serialcardiacenzymes,serialEKG’s
• 3EKGstagesofacuteMI– 1.Twavepeaksandtheninverts– 2.STsegmentelevates– 3.Qwavesappear
QWaves
• CriteriaforsignificantQwaves– Qwave>0.04secondsinduraCon– Qwavedepth>⅓heightofRwaveinsameQRScomplex
• CriteriaforNon-QWaveMI– Twaveinversion– STsegmentdepressionpersisCng>48hoursinappropriateclinicalse{ng
LocalizingMIonEKG• InferiorinfarcCon–leadsII,III,aVF
– OVencausedbyocclusionofrightcoronaryarteryoritsdescendingbranch
– ReciprocalchangesinanteriorandleVlateralleads• LateralinfarcCon–leadsI,aVL,V5,V6
– OVencausedbyocclusionofleVcircumflexartery– Reciprocalchangesininferiorleads
• AnteriorinfarcCon–anyoftheprecordialleads(V1-V6)– OVencausedbyocclusionofleVanteriordescendingartery– Reciprocalchangesininferiorleads
• PosteriorinfarcCon–reciprocalchangesinleadV1(STsegmentdepression,tallRwave)– OVencausedbyocclusionofrightcoronaryartery
LocalizingMIonEKG
STsegment• ElevaCon– SeenwithevolvinginfarcCon,Prinzmetal’sangina– Othercauses–JpointelevaCon,apicalballooningsyndrome,acutepericardiCs,acutemyocardiCs,hyperkalemia,pulmonaryembolism,Brugadasyndrome,hypothermia
• Depression– SeenwithtypicalexerConalangina,non-QwaveMI– Indicatorof+stresstest
ElectrolyteAbnormaliCesonEKG
• Hyperkalemia–peakedTwaves,prolongedPR,flagenedPwaves,widenedQRS,mergingQRSwithTwavesintosinewave,VF
• Hypokalemia–STdepression,flagenedTwaves,Uwaves
• Hypocalcemia–prolongedQTinterval• Hypercalcemia–shortenedQTinterval
Drugs• Digitalis– TherapeuCclevels–STsegmentandTwavechangesinleadswithtallRwaves
– Toxiclevels–tachyarrhythmiasandconducConblocks;PATwithblockismostcharacterisCc.
• MulCpledrugsassociatedwithprolongedQTinterval,Uwaves– Sotalol,quinidine,procainamide,disopyramide,amiodarone,dofeClide,dronedarone,TCA’s,erythromycin,quinolones,phenothiazines,variousanCfungals,someanChistamines,citalopram(onlyprolongedQTinterval–dose-dependent)
EKG∆’sinotherCardiacCondiCons• PericardiCs–DiffuseSTsegmentelevaConsandTwaveinversions;largeeffusionmaycauselowvoltageandelectricalalternans(alteringQRSamplitudeoraxisandwanderingbaseline)
• MyocardiCs–conducConblocks• HypertrophicCardiomyopathy–ventricularhypertrophy,leVaxisdeviaCon,septalQwaves
EKG∆’sinPulmonaryDisorders
• COPD–lowvoltage,rightaxisdeviaCon,andpoorRwaveprogression.
• Chroniccorpulmonale–PpulmonalewithrightventricularhypertrophyandrepolarizaConabnormaliCes
• Acutepulmonaryembolism–rightventricularhypertrophywithstrain,RBBB,andS1Q3T3(withTwaveinversion).SinustachycardiaandatrialfibrillaConarecommon.
EKG∆’sinOtherCondiCons• Hypothermia–Osbornwaves,prolongedintervals,sinusbradycardia,slowatrialfibrillaCon,bewareofmuscletremorarCfact
• CNSDisease–diffuseTwaveinversionwithTwaveswideanddeep,Uwaves
• Athlete’sHeart–sinusbradycardia,nonspecificSTsegmentandTwavechanges,RVH,LVH,incompleteRBBB,firstdegreeorWenckebachAVblock,possiblesupraventriculararrhythmia
UgerConfusion
• Verifyleadplacement• RepeatEKG• RepeatstandardizedprocessofEKGanalysis-starCngoverfromthebeginningwithbasics–rate,intervals,axis,rhythm,etc.andproceedthroughenCrestepwiseanalysis
• ConsiderCardiologyconsultaCon
ArrhythmiaIndicaConstoConsultCardiology
• DiagnosCcormanagementuncertainty• MedicaConsnotcontrollingsymptoms• PaCentisinhigh-riskoccupaConorparCcipatesinhigh-riskacCviCes(pilot,scubadriving)
• PaCentsprefersintervenConoverlong-termmeds• PreexcitaCon• Underlyingstructuralheartdisease• Associatedsyncopeorothersignificantsymptoms• WideQRS
CareConsideraConsPriortoCardiologyConsult
• ThoroughHxandPE• Basiclabs• EKGandrepeatEKG• Holtermonitor• Echocardiogram• Acuityofcarerequired–considerrisks,hemodynamicstability
PacemakerConsideraCons
• Third-degree(complete)AVblock• SymptomaCclesserdegreeAVblockorbradycardia
• SuddenonsetofvariouscombinaConsofAVblockandBBBduringacuteMI
• Recurrenttachycardiasthatcanbeoverdrivenandterminatedbypacemakers
OsteopathicConsideraCons
• Treatments–– LymphaCcs–thoracicinlet,abdominaldiaphragm,ribraising,lymphaCcpumps
– SympatheCcs(T1-T6)–cervicalganglion,ribraising,T1-T6,Chapman’sreflexes,T10-L2foradrenal/kidney
– ParasympatheCcs–OA/AA/cranial–vagusnerve
ClinicalCases/EKG’s
Case1• 53yearoldcaucasianfemalewith4dayhxofseverecentralchestpainonexerCon,previouslyalleviatedwithrest;nowworsenedoverlast24hoursandsustainedatrest
• 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;lossofominoustombstoneeffect;Qwavesdeveloping
Case2
• 45yomalepresentswithacuteSOBs/plongvacaConinParis
• PMHx-asthma,Crohn’sdisease,anxiety,GERD,tobaccoabuse
• VS37,148/92,130,26• PaCentappearsuncomfortablebutotherwiseunremarkableexam
Case2
• Diagnosis?EKGfindings?
Case2
• AcutePEwithsinustachycardia,aPVC,andS1Q3T3pagern
Case3
• 72yomalepresentstotheofficeforevaluaConpriortocataractsurgery
• Nocomplaints• PMHx–B/Lcataracts,OA,HTN,hyperlipidemia,andchroniclowbackpain
• VS37.2,152/86,74,14
Case3
• Diagnosis?EKGfindings?
Case3
• LVH–QRSvoltagecriteriainprecordialleadsandrepolarizaConchangesinV5,V6
Case4
• 27yofemalepresentstotheEDwithc/ochestdiscomfortandpalpitaConsaVerstudyingallnightforgraduateschoolexams
• Appearsnervousand“uneasy”withrapidpulse
• PMHx–unremarkable;nomeds,admitstooccasionalalcohol,non-smoker,deniesillicitdruguse,usedcoffeetostayawaketostudy
Case4
• Diagnosis?EKGfindings?
Case4
• SVT–regular,narrow-QRStachycardia,rateof160bpm
Case5
• 46yomalepresentstoEDwithc/osevereHApersisCngover5hoursdespiteacetaminophenandNSAIDagemptsasaborCvetherapy
• PMHx–occasionalleVshoulderpain,non-smoker
• ConstrucConworker• VSS;unremarkableexam
Case5
• Diagnosis?EKGfindings?
Case5
• NormalEKG
Case6
• 56yofemalepresentstofamilyphysicianwithc/olight-headednessandoccasionalflugerinherchest
• PMHx–anxiety,depression,obesity,smoker• Worksasretailstoremanager• VSS;coursebreathsounds,otherwiseunremarkableexam
Case6
• Diagnosis?EKGfindings?
Case6
• SeconddegreeAVblock–MobitzTypeI–Wenckebach(specifically3:2AVWenckebachphenomenonwhereevery3rdPwaveisblocked)
Case7
• 28yomalepresentsforcommercialdriver’slicense(CDL)evaluaCon
• Nocomplaints• VSS;asymptomaCc;examwithoutsignificantfindings
Case7
• Diagnosis?EKGfindings?
Case7
• TypicalpreexcitaCon(WPW)pagern• ShortPRintervalanddeltawavesinmanyleads
• TxiscloseobservaConunlesspaCenthashadSVToratrialfibrillaConwhichindicatestxwithablaConofaccessorypathway
Case8
• 32yomalepresentstoEDwithc/ofeelingsickforthelast6days
• Symptomsincludefevers,cough,anddifficultycatchinghisbreath
• PMHx–hyperlipidemia,obesity,metabolicsyndrome
• VS38.1,105,128/84,22
Case8
• Diagnosis?EKGfindings?
Case8
• AcutepericardiCs–diffuseSTelevaConwithPRsegmentdepressionisdiagnosCc
Case9
• 67yomalepresentstohiscardiologistforout-paCent6weekpost-hospitalvisit
• PrevioushospitalizaConfornon-cardiacchestpain
• Post-hospitalcardiacmeds–ACEinhibitor,betablocker,aspirin,nitrate
• Nocurrentcomplaints
Case9
• Diagnosis?EKGfindings?
Case9
• AtrialfibrillaCon–irregularlyirregularwithoutPwaves
• RBBB–wideQRSwithrsR’pagerninV1,broadSwavesinleadsIandaVL
• Inferiorinfarct–non-acute(>1week)pathologicQwavesininferiorleads(II,III,andaVF)
Case10
• 79yomalebroughttoEDviaEMSwithchestpain,SOB,andnear-syncope
• PMHx–unobtainablesecondarytopaCentdistress
• VS–36.9,140’s,82/40,28
Case10
• Diagnosis?EKGfindings?
Case10
• Monomorphicsustainedventriculartachycardia(VT)–couldrapidlydeteriorateintoVF,torsadesdepointes,asystole,orsuddendeath
Case11
• 82yofemaleadmigedtoacutecarehospitalsecondarytochestpain
• PMHx–HTN,DM2,CHF,obesity,depression• CardiologyplanningcardiaccatheterizaConsecondarytonewfindingduringiniCalconsultaCon
Case11
• Diagnosis?EKGfindings?
Case11
• LBBB–wideQRS;broad,notchedRwaveinV5,V6andIwithSTdepressionandTwaveinversion
Case12
• 59yomalepresentstoEDdiaphoreCcandindistress
• PMHx–HTN,ESRD,DM2,LeVBKA• VS–37.5,108,96/58,24
Case12
• Diagnosis?EKGfindings?
Case12
• Hyperkalemia–tallpeakedTwavespresentthroughout;otherprogressiveEKGchangesmayfollowwithincreasingpotassiumlevels–prolongedPRinterval,flagenedPwaves,wideningQRS,sinewaves
• Sinustachycardiaalsopresent
BonusCase
• 18yomaleundergoingmilitaryphysicalexamandevaluaConpriortobootcamp
• Nocomplaints• PMHx–denies• VSS;examunremarkable
BonusCase
• Diagnosis?EKGfindings?
BonusCase
• Reversedarmleads–invertedPwavesinleadIwithnormalRwaveprogressioninprecordialleads
BoardExamPoints
• EKG’slikelytohave1mainfinding• ClinicalcaselikelyincludedwitheachEKG• QuesConlikelytofocusonclinicalcaseaswellasEKG
• Straightforwardwithouttricksorobscurefindings(notlikelytosee“zebras”)
• Focusoncommonarrhythmias,commoncardiacdiagnoses,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