ECG Solving & Cardiac Cases ECG Solving & Cardiac Cases Mangement in Family MedicineMangement in Family Medicine

DR Ihab Suliman MBBS , MRCP, Diplomate Certification Board of Nuclear

Cardiology(USA)

28 years old school teacher, Mother of 3 children visited

Family medicine clinic with Chest pain & Palpitations

Normal

Lead PositionLead Position A typical ECG report shows the cardiac cycle from 12

different vantage points (I, II, III, aVR, aVL, aVF, V1-V6), like viewing the event electrically from 12 different locations (like a 3D perspective).BUT only 10 electrodes are used.

Lead I represents activity that is going from the right arm to the left arm

Lead II represents activity that is going from the right arm to the left leg

Lead III represents activity that is going from the left arm to the left leg

aVL is placed on the left arm (or shoulder) aVF is placed on the left leg (or hip) aVR is placed on the right arm (or shoulder) V1- 4th intercostal space to the right of sternum V2- 4th intercostal space to the left of sternum V3- halfway between V2 and V4 V4- 5th intercostal space in the left mid-clavicular line V5- 5th intercostal space in the left anterior axillary line V6- 5th intercostal space in the left mid axillary line

QRS waveform nomenclatureQRS waveform nomenclature

R r qR qRs Qrs QS

Qr Rs rS qs rSr’ rSR’

Mil

liv

olt

s

Milliseconds

0 200 400 600

-0.5

0

0.5

1.0

QRS

P

R

T

Q

S

The width of the QRS complex should not exceed 110 ms, less than 3 little squares

I II III aVR aVL aVF

The QRS complex should be dominantly upright in leads I and II

I II III aVR aVL aVF

QRS and T waves tend to have the same general direction in the limb leads

V1

V2

V3

V4

V5

V6

The R wave in the precordial leads must grow from V1 to at least V4

QuestionQuestion

An 8 years old boy presents with history of chest pain that gradually worsened while he was watching television with his mother. The pain lasted 2 hours and then resolved without intervention. There was no associated dyspnea or syncope. He has no significant past medical history. Family history includes a grandmother who died of a heart attack. Physical exam, ECG, and CXR are normal. What is the most appropriate next step in the emergency department?

AnswerAnswerA. Administer salbutamol and check peak flow

B. Discharge home with primary care followup

C. Laboratory evaluation, including cardiac markers

D. Observation admission for treadmill testing

E. Outpatient echo and Holter monitor

A. Administer Salbutamol and check peak flow– Not indicated by the history

B. Discharge home with primary care followup– Reasonable for 1st episode with reassuring story

C. Laboratory evaluation, including cardiac markers– No clear evidence for trops in kids

D. Observation admission for treadmill testing– Evals for CAD, very rare in kids

E. Outpatient echo and Holter monitor– May be indicated for recurrent episodes

53 years old male with Previous history of pontine 53 years old male with Previous history of pontine Hemorrhage , visited the clinic with Chest Pain, 2 sets Hemorrhage , visited the clinic with Chest Pain, 2 sets

of cardiac Enzymes are Normal of cardiac Enzymes are Normal

A 49 yo M presents after he fainted while running on his treadmill at home. He has been having exertional dyspnea and angina for the past several months. Which of the following disease is most likely to cause these symptoms?

NSR, LVH + LV Strain Pattern

Exertional Syncope case

49 years old male healthy looking , does regular exercise at home using treadmill testing , last Night had syncope after 5 minutes on treadmill , no fits.

Visited today Family Practice Clinic , ECG showed LVH , NSR , BP 120/70

AnswerAnswerA. Aortic stenosis

B. Pulmonary embolus

C. Mitral incompetence

D. Pulmonary stenosis

E. Tricuspid incompetence

AnswerAnswerA. Aortic stenosis

– Fits the age group for congenital bicuspid valve

B. Pulmonary embolus– Usually more acute, not exertional

C. Mitral incompetence– SV maintained -> exertional SOB but not syncope

D. Pulmonary stenosis– Dyspnea and Easy Fatigability

E. Tricuspid incompetence– Causes JVD and peripheral edema (right sided)

Aortic StenosisAortic Stenosis

Bimodal distribution– Under 65: bicuspid aortic valve– Over 65: calcific degeneration

Outflow tract obstruction with LVHCrescendo-decrescendo systolic murmur Classic symptoms

– DOE– Syncope– Angina

This is the classic AS question

35 years old , Lady seen in Family Practice Clinic for Vague Sx , including Chest Pain.

NSR, First Degree AV Block

50 years old lady with Rheumatic Heart Disease & Open Heart Surgery 15 years ,triple valve replacement , came to the clinic with SOB , ECG & CXR were done

AF with Controlled Ventricular rate .

65 years old male with Recurrent Heart Failure & non-ischemic Cardiomyopathy was admitted Electively to CCU .

ECG oredered

NSR , LBBB

16 years old female admitted to HDU for elective cardiac procedure.

H/O rheumatic Heart Disease.

ECG ordered showed

Sinus Tachycardia , Bi atrial Enlargement.

Left Atrial Enlargement

40 years old male , hospital staff , LDL is 3.5, strong Family history of IHD, occasional Chest Pain.

ECG ordered

Normal , next step is stress Test

65 year old man(H/O DM,HTN) presented with a 1 hour history of 65 year old man(H/O DM,HTN) presented with a 1 hour history of severe central crushing chest pain. He is sweaty, clammy and has severe central crushing chest pain. He is sweaty, clammy and has

vomited twice .vomited twice .

65 year old man(H/O DM,HTN) presented with a 1 hour history of 65 year old man(H/O DM,HTN) presented with a 1 hour history of severe central crushing chest pain. He is sweaty, clammy and has severe central crushing chest pain. He is sweaty, clammy and has

vomited twice .vomited twice .

Anterior (extensive) Myocardial infarction.

Why ?

Male 65 years.

H/O DM+HTN( remember INTERHEART study)

Crushing chest pain.

Associated sweaty,clammy,vomiting.

A 26 year old woman presented 1 week post A 26 year old woman presented 1 week post delivery of her first baby. She has sharp L sided delivery of her first baby. She has sharp L sided

chest pain and she is short of breath.chest pain and she is short of breath.

Pulmonary EmbolismWhy ?Young femalePegnancy hypercoagulable stateOccurrence one week post partum

50 years old female with chronic renal failure,chest 50 years old female with chronic renal failure,chest pain & dizzinesspain & dizziness

she is hypertensive on lisinoprilshe is hypertensive on lisinopril

Hyperkalemia,tall tented T-wave & bradycardia.

Why ?Chronic renal failurePatient on lisinopril

26 Old army officer had flu last week,felt chest pain while driving his 26 Old army officer had flu last week,felt chest pain while driving his car,pain increased by deep breath,he has no history of DM or car,pain increased by deep breath,he has no history of DM or

HTN,nonsmoker,lipid profile LDL 2.0 MMMOL/HTN,nonsmoker,lipid profile LDL 2.0 MMMOL/LL

Acute Pericarditis

26 Old army officer had flu last week, felt chest pain 26 Old army officer had flu last week, felt chest pain while driving his car, pain increased by deep breath, while driving his car, pain increased by deep breath,

ECG after 5 daysECG after 5 days..

Resolved Pericardtis.

47 years old lady mother of 5 children , visited Family Practice Clinic with Palpitations , ECG oredered

S Tachycardia , LVH + LAE

Thank You Very Much