ECG Underwriting Puzzler

Presented by: Bill Rooney, M.D.

Obtaining Best Results from this presentation

• Select “From the beginning”

2

For best results—please do the following:• Select “Slide Show” from the menu

option on top

• Slowly click through the presentation• Have fun!---Good luck

ECG Puzzler 3

QUESTION????How would you interpret this ECG?

4

If you said It looks normal other than for one PVC you were correct. PVC’s can exist in many forms and configurations. Always be on the lookout!!

I will take you down the road of PVC’s and the mischief they can cause.

ECG Puzzler 5The PVC can be seen in several leads below. It is the same PVC but seen from different angles. PVC’s are early occurring beats with a wide (typically >0.16 sec) QRS complex.

ECG Puzzler 6

PVC’s have a QRS

morphology that is

different th

an the sinus

QRS complexes.

PVC’s typically have

marked repolarization

abnormalities.

PVC’s_____________________________

Facts to Know

If several PVC’s are present and they all have the same QRS morphology they are

called unifocal PVC’s. But, if those PVC’s have different

QRS morphologies then they are referred to as multifocal

PVC’s.When a PVC alternates

with a normal sinus

beat this is called

ventricular bigeminy.

A PVC every third beat

is ventricular trigeminy.

2 PVC’s in a row are called a

ventricular couplet. 3 PVC’s

in a row are called a

ventricular triplet but 3 or

more PVC’s in a row are also

called ventricular tachycardia.

The Many Faces of PVC’s7

Multifocal PVC

V-tach

Single PVC

Triplet PVC’s

CoupletBigeminy

One more ECG to consider 8

QUESTION????How would you interpret this ECG?

What is that strange beat??? 9

Is that artifact in leads I, II, and III or is it an abnormality?

Answer:The wide and bizarre beat, which is seen in multiple leads, is a PVC.

Other than the PVC the ECG looks to be WNL.

ECG Puzzler 10

Here is a rhythm strip from the previous slide

This is called a “compensatory pause”. The pause allows the

ventricles to reset and be ready for the next impulse coming down from

the SA node.

Interpolated PVC’s are rare. The PVC is “sandwiched” in between 2 normal

beats and there is no pause.

If the ventricle however is ready for the impulse then the next normal QRS complex occurs as scheduled and

causes the PVC to become interpolated”.

Single PVCThe SA node continues to fire but the beat is not

conducted as the ventricle is just not ready for it yet. The p wave gets buried in the QRS complex

somewhere.

Notice the pause after the PVC?

11

That concludes this issue of the ECG Puzzler!! Contact

me if you have any questions!!

PVC’s

For further reading:Please see page 137 in Dale Dubin’s 6th edition of Rapid

Interpretation of EKG’s

There are no additional mortality concerns with interpolated PVC’s

versus PVC’s with the compensatory pause but it remains important to be able to recognize

them.

ECG Solved