ECG OF THE WEEKProf.Dr . G.ELANGOVAN’S unit

Dr.M.Amudhan

73 year old male presented with c/o giddiness on & off

for past 1yr. chest pain past 2 days

Past history; not a k/c/o T2DM/SHT/IHD No other significant history

O/E pt concious ,oriented, afebrile. no pallor/icterus/cyanosis/clubbing/LN/pedal

edemaVitals; PR 84/min BP 150/90Cvs: s1 s2 heard. No murmurs.RS: nvbs heard, no added sounds,Other systems also normal.

In this ECGRate – 80/minRhythm – sinus rhythm P wave morphology – normal PR interval – 0.24 sQRS duration – 0.16 s, QRS axis: - 40 degrees QRS morph. – RR’(M pattern) in V5,V6,aVL &

L1 with secondary ST-T Changes Deep S waves in V1-V3 & L2 & L3

ST eievation in V1 – V3

ECGLBBB + First degree AV block POSSIBLE TRIFASCICULAR BLOCK WHICH HAS TO BE CONFIRMED ONLY BY HIS BUNDLE ELECTROGRAM

INTRA – VENTRICULAR CONDUCTION DEFECTS

• Abnormality in conduction thru one or more divisions of intra ventricular conduction system distal to Bundle of His

• Various conduction defects include:-

RBBB LBBB LAFB LPFB Parietal Block Peri Infarction Block

Causes Of IVCD :-

1. Congenital ( RBBB in normal individuals )

2. IHD ( AMI / PMI / Coronary atherosclerosis )

3. Cardiomyopathy ( DCM / HCM )4. Infiltrative Lesions ( Tumors / Chagas /

Hypothyroidism / Amyloidosis )5. Aortic stenosis ( LBBB )6. Infective Endocarditis7. Hyperkalemia8. Cardiac Injury9. Massive Pulmonary Embolism10.Ventricular Hypertrophy11. Myocarditis

FASCICLE BLOCK - TYPES Unifascicular Block LAFB LPFB RBBB Bifascicular Block LBBB RBBB + LAFB RBBB + LPFB Definite Trifascicular Block Alternating BBB RBBB + alternating fascicular block RBBB + Mobitz type 2 second Deg AV Block LBBB + Mobitz type 2 second Deg AV Block Possible Trifascicular Block Complete AV Block with ventricular escape rhythm Any Bifascicular Block + 1ST or 2nd deg AV Block

FASCICULAR BLOCKSLAFB• LAD (-30 to -80 )•rS in L2,3,aVf•R in aVL ,L1•Absent q in V5 V6•RS in V5 V6

LPFB•RAD ( +120 to + 180 )•rS in aVL , L1, V1 V2•R in L2 L3 aVF•Rs in V5 V6

•QRS duration Normal•Increased QRS voltage•Increased VAT•Sec ST / T wave changes

LBBB• 1st degree:- q in V5 V6 disappears

r in V1 V2 disappears

• 2nd degree:- initial slurring of R wave in V5 V6QRS 0.10 – 0.12 secVAT 0.06 – 0.09 secSec ST / T wave changes

• 3rd degree :- wide slurred R wave in V5 V6RR’ / rSR’ / RSR’ pattern QRS >0.12 secVAT > 0.09 secSec ST / T wave changes

THANK YOU