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SHIVDA PANDEY, PGY-6MARK VILLALON, PGY-6
BOSTON MEDICAL CENTERCARDIOVASCULAR FELLOWS
ECG Master SessionSENIOR RESIDENT EDITION
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What is your ECG diagnosis? PCP Clinic Visit
65 year old male with PMH hypertension and active smoking is in your clinic for an initial evaluation.
He has no complaints and feels well. Routine ECG is performed in light of his cardiac risk factors
and reveals the following:
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What is your diagnosis?
A. I know the diagnosis and can teach this concept to my 3rd year med student
B. I’m pretty sure about this diagnosisC. I’m not very sure about this diagnosisD. What does the automated read say?
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Diagnosis
Step 1: Normal sinus rhythm** Always start with the
rhythm**
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“NSR is not “There’s a P before every QRS”
“There’s a P before every QRS” This does not define NSR Can be seen in flutter, a-tach etc
Sinus rhythm = Upright P’s in: Lead I, II and aVF
Right to left activation
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Diagnosis
1. NSR2. Wow, is that QRS wide or something?
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Sinus rhythm and the wide QRS
100 msec 120 msec
Normal QRS width IVCD“Incomplete RBBB”“Incomplete LBBB”
LBBBRBBBIVCD
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South Shore Plaza
Fast Slow
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LBBB: RV contracts, then LV contracts
V6 V6
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Left Bundle Branch Block
QRS > 120 msecV5-V6: Broad R waveI + aVL: Absence of Q wave
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RBBB: Left ventricle contracts, then right ventricle contracts
QRS > 120 msec
V1-V2: RSR’Lateral leads:
Deep terminal S wave
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A. IVCDB. RBBBC. LBBB
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A. IVCDB. RBBBC. LBBB
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A. IVCDB. RBBBC. LBBB
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“When I go fast, I go wide”
Rate-related aberrancy Usually RBBB,
but can be LBBB Refractoriness Clinical
significance: At faster rates, need to differentiate VT vs SVT with aberrancy
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PA catheter insertion Pt with LBBB
Complete heart block. Hopefully there’s an escape rhythm. Watch the monitor during insertion.
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55M with PMH DM2 and smoking p/w 1hr of “crushing” chest pain. ECG from last
week with NSR and normal QRS width. Dx? Mx?
A. New LBBB. Wait for the enzymes.
B. New LBBB. Admit to Obs unit.
C. New LBBB. Call cards fellow to activate the cath lab STAT.
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55M with PMH DM2 and smoking p/w 1hr of “crushing” chest pain. ECG from last week with NSR and normal QRS width. Dx? Mx?
A. Old LBBB. Wait for the enzymes.B. Old LBBB. Admit to Obs unit.C. Old LBBB + acute MI. Call cards fellow
STAT.D. This is a trick question.
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Discordant:QRS deflection is
opposite of T wave deflection
Concordant:QRS deflection is
the same of T wave deflection
Normal in LBBB and paced rhythm
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How to diagnose an acute MI in pt with LBBB (or paced rhythm)
ST elevation ≥1 mm in a lead with upward (concordant) QRS complex - 5 points
ST elevation ≥5 mm in a lead with downward (discordant) QRS complex - 2 points
ST depression ≥1 mm in lead V1, V2, or V3 - 3 points
≥3 points = 90% specificity of STEMI (sensitivity of 36%)
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Thank you