Intermediate ECG Course - Part 4Topics in Intermediate ECG •Consolidation of prior information...
Transcript of Intermediate ECG Course - Part 4Topics in Intermediate ECG •Consolidation of prior information...
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Intermediate ECG Course - Part 4
Joe M. Moody, Jr, MD
UTHSCSA and STVAHCS
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Topics in Intermediate ECG• Consolidation of prior information with additional
details
• Not “advanced”, but feel free to ask advanced
questions
• Causes of axis deviation and wide QRS (1)
• Infarction and causes of ST segment shifts (2)
• Electrolyte effects on the ECG (2)
• Flutter versus fib, and ventricular patterns (3)
• AV conduction and AV dissociation (4)
• Tachyarrhythmias, wide and narrow QRS (5, 6)
• Integrating ECG and clinical information (7,8)
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Atrial Flutter
• Organized reentry in the atrium at rate of 250-350 waves/min, consistent
• Waves best in II, III, and aVF, sawtooth
• Ventricular response
– may be 2:1 AV conduction, regular at 150 beats/min
– may be variable
– may alternate 2:1 and 4:1 conduction
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Atrial Flutter• Classic (Type I, “common”, “typical”) Atrial Flutter:
rate 240-350/min, single right atrial macroreentrant circuit including slow conduction in the subeustachian isthmus– Usually counterclockwise circuit: up the interatrial
septum, down the atrial free wall, and along the crista terminalis counterclockwise
– Ablation across the subeustachian isthmus, between the TV annulus and the IVC is curative
– Clockwise circuit in same path may occur
• Type II (“atypical”, “uncommon”) has faster rate (>340), is heterogeneous, transitional to atrial fibrillation
Surawicz B et al. p. 351, Chou’s Electrocardiography in Clinical Practice, 5th
ed. 2002.
Zipes DP et al. “Genesis of Cardiac Arrhythmias: Electrophysiological
Considerations” p. 680. in Braunwald’s Heart Disease, 7th ed. 2005.
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Atrial
Flutter
Slow conduction
IVC
Type I,
common type
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Atrial Flutter
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Atrial Flutter
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Atrial Flutter
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Atrial Flutter
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Atrial Fibrillation
• Disorganized atrial rhythm, faster than 350
• Usually best in V1
• Moderate ventricular response is 70-110
beats/min
• Irregularly irregular (no pattern) RR interval
• If regular RR interval, then the ventricle is
beating on its own
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Atrial Fibrillation
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Atrial Fibrillation
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Atrial Fibrillation
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Multifocal Atrial Tachycardia
• Variable P morphology and PR interval
and P-P interval, not gradual or
progressive
• Rate over 100 beats/min
• Often indicates severe end-stage
cardiac or pulmonary disease
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Multifocal Atrial Tachycardia
Lead II
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Case 4
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Case 13
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Steps in Arrhythmia Analysis
• Find all the QRS’s and check out their rate, regularity, uniformity and shape
• Find all the P’s and check out their rate, regularity, uniformity and shape
• Deduce the origin of the P wave from the shape
• Deduce the relationship of the P and QRS by the PR interval characteristics and P wave shape
• Determine the cause of each wave using known electrophysiologic principles (automaticity, triggered activity, reentry, refractoriness, aberrancy)
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AV Block: Outline
• Review of anatomy of conduction system
• Description of types of AV block
• Other considerations
– Distinguishing from AV dissociation without block
– Information from the QRS
• Escape mechanism
• Morphologic information: Injury, Electrolyte
– Effects on the Atrium
• Ventriculophasic sinus arrhythmia
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• Normal variant; Congenital (isolated, corrected transposition)
• Iatrogenic
• Coronary artery disease (acute ant or inf MI)
• Valve disease – calcific aortic stenosis (?Lev)
• Degenerative conduction system disease (Lenegre)
• Cardiomyopathy – sarcoid, primary dilated, amyloid, hemachromatosis, progressive muscular dystrophy,
• Inflammation/infection/metabolic – acute myocarditis, Chaga’s cardiomyopathy, lyme disease; lupus, dermatomyositis, scleroderma, Reiter’s syndrome, Marfan’s syndrome, rheumatoid heart disease, ankylosing spondylitis; hyperkalemia or mag
• Hereditary with DCM
– Autosomal dominant DCM lamin A/C defect
– Emerin defects also manifest AV conduction disease
• Isolated CHB in neonate or fetus is ominous, highly associated with anti-Ro and anti La, and with 6% and 43% mortality, respectively; in children, antibody association was 5% and mortality was 0
Arbustini E et al. JACC 2002; 39:981; Jaeggi ET et al. JACC
2002; 39:130
Causes
of AV
Block
OSA
–vagal, negative dromotropic agents
–Surgery (VSD, AVR), septal ablation, radiofreq
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Degrees of AV Block
Degree of
Block
Which
ConductPR interval RR interval
First AllConstant
and longRegular
Wenckebach
(Mobitz I)Some
Variable,
progressive
Grouped
beating
2:1 Some Constant Regular
Mobitz II Some Constant Pauses
Third NoneVariable,
randomRegular
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First Degree
AV Block
PR interval
Constant
and
Long
PR 0.22
PR 0.28 PR 0.24
PR 0.38
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• Some beats don’t conduct, so more P’s
than QRS’s
• Progressive Prolongation of the PR interval
for the conducted beats
– increment of prolongation actually decreases
– progressive shortening of the RR interval
• After pause is shortest PR interval
– may be a junctional or ventricular escape beat
Second Degree AV Block,
Wenckebach (Mobitz I)
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Second Degree AV Block,
Wenckebach (Mobitz I)
0.32 0.38 block 0.32 0.400.32 0.40 0.45 block
2:1 2:1
Grouped beats
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Wenckebach: The RR
Decreases(The PR increases)
Wagner GS. Marriott’s Practical Electrocardiography 1994, p.390
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Second Degree AV Block,
Wenckebach (Mobitz I)
V1
II
Non-simultaneous
3:2
Low grade block
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Wenckebach Caveats
• Block is usually in the AV node
• Blocked beat will have no His bundle potential
• If intrahisian, there will be split His potentials and blocked beat will have no second His potential (worsen with Atropine)
• If associated with BBB, still 75% are AV node, and only 25% infranodal
• Exceptions to the usual periodicity are more common than the rule
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Second Degree AV block, 2:1
• Can be either mechanism of Wenckebach or mechanism of Mobitz II, can’t tell– if QRS is wide, could be either
– if QRS is narrow, usually is Wenckebach
• Can be tricky to diagnose, must find the nonconducted P waves (otherwise the mistaken diagnosis will be mere bradycardia)
• “It is advisable to be noncommittal as to the type of Mobitz block when dealing with 2:1 AV block”
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Second Degree AV block, 2:1
easy
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Second Degree AV block, 2:1
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Second Degree AV block, 2:1
• Not so easy… could misdiagnose as NSR rate 64.
• But actually is sinus tachycardia at rate of 128 (patient is
likely sick) with 2:1 block.
• The extra P waves are best seen at the 3 red arrows, and
are same shape and axis as the sinus P waves.
• Wide QRS indicates disease below the bundle of His.
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Second-Degree AV Block, Mobitz II
• Intermittent blocked P waves
• PR interval constant for conducted beats
• Most are associated with BBB
• About 1/3 of patients with Mobitz II have
block located in the His bundle, so QRS is
narrow
• Rarely Mobitz II is due to block in the AV
node
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Second-Degree AV Block, Mobitz II• Intermittent blocked P waves
• PR interval constant for conducted beats
• Most are associated with BBB
• About 1/3 of patients with Mobitz II have block located in the His
bundle, so QRS is narrow
• Rarely Mobitz II is due to block in the AV node
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Advanced AV block
• Block is 3:1or higher
• Sometimes only occasional ventricular
captures are observed, sometimes
more frequently
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Third Degree AV block
(Complete Heart Block)
• No atrial activity conducts to the ventricle
• Atrial rate faster than ventricular rate
• No relationship between P and QRS• PR interval is random
• PR interval may at first glance seem to have a
pattern, but don’t be fooled
• Retrograde conduction is possible
• Ventricular rhythm is independent, either
junctional or ventricular escape rhythm• Regular ventricular rhythm, even in Afib
Eliminates
AV dissociation
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Third Degree AV Block
Retrograde conduction
Surawicz B et al. Chou’s ECG… 2001, p.439
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Third Degree AV block - 2
• Site of block: AV junction, His bundle, or
bundle branches (either bilateral bundle
branch, or trifascicular block)
• Adult acquired chronic: 50-60% are
infrahisian and escape complexes are
wide
• Acute block from drugs, infection or
inferior MI: usually proximal to His bundle
• Anterior MI: usually distal to His bundle
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Third Degree AV block
(Complete Heart Block)
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Third Degree AV block
(Complete Heart Block)
Wide QRS - ventricular escape
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Third Degree AV block
(Complete Heart Block)
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Third Degree AV block
(Complete Heart Block)
Narrow QRS - junctional escape
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Third Degree AV block
(Complete Heart Block)
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Third Degree AV block
Wide QRS (LBBB pattern) - ventricular escape.
Acute inferior injury pattern!
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Third Degree AV block
Atrial fibrillation with narrow QRS - junctional escape.
Acute inferior injury pattern!
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Unknown
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Pseudo AV Block
• Most common cause of a pause – a non-conducted PAC (but don’t be led astray by ventriculophasic sinus arrhythmia)
• Concealed His bundle extrasystole
• AV junctional parasystole with concealed conduction
• Concealed junctional discharges can delay a normal junctional escape rate
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AV Dissociation
• Definition: Variability of the PR interval
without heart block
– Atrial and ventricular activities are independent
– Ventricular rate is faster than atrial
– No retrograde conduction
• AV dissociation is always a secondary
diagnosis, consequent to a primary problem
of automaticity or reentry, and the clinical
significance is determined by the primary
disorder
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Terminology in AV Dissociation
• Usurpation:– The ventricular rhythm is
too fast, usurping the normal atrial mechanism
– Ventricular rate is generally normal or fast
• Default:– The atrial rhythm is too
slow, defaulting to the normal escape ventricular mechanism
– Ventricular rate is generally slow
• Complete AV dissociation: there is no connection between atrial and ventricular complexes
• Incomplete AV dissociation: there is evidence of AV conduction causing an early QRS complex
• Interference dissociation: incomplete AV dissociation
• Isorhythmic AV dissociation: the PR interval varies but the atrial and venticular rates are identical
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What is the rhythm?
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Sinus Tachycardia, PVC’s and fusion beats,
accelerated junctional rhythm, PAC’s
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What is the Rhythm?
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Sinus rhythm, Accelerated Junctional rhythm, PVC’s
15 P waves, 17 QRS complexes
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What is the rhythm?
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Sinus bradycardia, junctional escape
rhythm, AV dissociation with interference
(incomplete AV dissociation)
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What is the rhythm?
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Junctional rhythm, sinus
bradycardia, AV dissociation
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What is the rhythm?
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Sinus bradycardia, junctional
escape rhythm, one capture
beat
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What is the rhythm?
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Junctional rhythm, sinus bradycardia, PAC’s,
some conducted, some aberrant, some
nonconducted
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What is the Rhythm?
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Sinus rhythm, sinus arrhythmia,
junctional escape rhythm,
isorhythmic AV dissociation
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What is the Rhythm?
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Sinus bradycardia, junctional
escape rhythm, AV dissociation
with interference, escape capture
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What is the rhythm?
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Junctional rhythm with RBBB or
ventricular escape rhythm,
isorhythmic AV dissociation, sinus
bradycardia
v
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What is the rhythm?
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Sinus tachycardia, junctional
tachycardia, incomplete AV
dissociation
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What is the rhythm?
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Ventricular tachycardia, sinus rhythm with sinus
rate slightly less than half the ventricular rate