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12-Lead EKG Interpretation - Oregon Society of Physician …oregonpa.org/resources/2015CME/Speaker...

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10/22/2015 1 Jon Tardiff, BS, PA-C OHSU Clinical Assistant Professor 12-Lead EKG Interpretation [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!
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Page 1: 12-Lead EKG Interpretation - Oregon Society of Physician …oregonpa.org/resources/2015CME/Speaker Presentations/Tardiff - EKG... · Normal 12-Lead ECG 26 Rapid Interpretation Tips

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!

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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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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

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10

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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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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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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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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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

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17

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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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°

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23

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

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27

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

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Acute R Ventricle MI Page

1/3 of Inferior MIs

Acute Lateral MI Page

15% of MIs

Acute Posterior MI Page

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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

[email protected]

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!

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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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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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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

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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!

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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

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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)

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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)

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• 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)

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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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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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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

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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.

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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!

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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

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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.

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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

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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

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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.

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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!

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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

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172

That’s all, Folks!

[email protected]


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