Important EKG’s
for the Geriatrician
Ned H. Gutman
8 September, 2011
Normal EKG
• Sinus rhythm-
– P waves upright inferior leads
• Normal axis/intervals/voltage
– Negative in aVR
• No pathologic Q waves
• Normal R wave transition
• Normal ST segments/T waves
LVH
• Important to recognize
• Prognostic implications
• “end organ” involvement
• Many criteria
S (V1 or V2) + R (V5 or V6) > 35 mm
R (V5 or V6) > 26 mm
EKG #2 49 yo asymptomatic man, no prev eval,
no meds, exercises 6+ days/wk
a) Normal EKG
b) LVH due to Aortic stenosis with
bicuspid aortic valve
c) LVH due to steroid use
d) Primary hypertrophic cardiomyopathy
e) LVH due to rheumatic mitral stenosis
EKG standard
• Speed 25 mm/s
• Standard box height 10 mm
• sharp corners
What do you call 2 orthopedists
reading an EKG?
• A double blind study
LBBB EKG #3a, 67 yo woman with class III
CHF, EF 20%, no CAD
• QRS >120 ms
• QS in V1 (sometimes small r wave)
• Monophasic R in V6
• If associated with LAD (>-30 deg),
higher incidence of CAD or myopathy
EKG #3b
• S/p BiV ICD
• Note small pacing spikes in rhythm strip
• Paced beats have a much narrower
complex, usually have shorter PR to
ensure mostly paced
• EF improved 45%
Abnormal Anterior T waves
• Strained T waves usually are directed opposite to the major QRS deflection, eg LVH, extreme T abn seen in HCM
• In BBB, the T wave is normally directed opposite to the terminal portion of the QRS
• Primary T abnormalities- may be seen in ischemia- aka Wellen’s sign
EKG #4
• 68 yo woman with new left CP, assoc
with SOB
• H/O breast ca, s/p left XRT, receiving
Hercepten
• Quit cigs 2 yr ago, M/Sis/Bro +CAD
• +HTN and Chol
• Cath-70% LM, 80% prox LAD ulcer
EKG #5
• 42 yo woman, s/p renal transplant,
treated HTN, new exertional chest and
arm tightness, marked LDL elev not
prev known (due to anti-rejection meds)
• Terminal T inv in V3 and V4
• 85% proximal LAD stenosis
EKG #6
• 58 yo man, atypical CP, hyperlipidemia
on statin
• Stress ECHO demonstrated apical
akinesis
• Cardiac cath- non critical LAD disease
• Small apical aneurysm
• Hypertrophic cardiomyopathy
Worcester
Gloucester
• Syncope
• loss of one or more sounds from the
interior of a word
Heart Block
Syncope due to transient heart block is
rarely seen with a normal baseline EKG
• Exercise induce heart block is very
specific for infra-nodal block
EKG 7
83 yo man • 1-2 months progressive exercise intol/DOE,
esp climbing stairs.
• No CP/palp/syncope
• CAD, s/p circ PCI 1999, nl nuc 2009
• CRI, creat 2’s, Diabetes
• Metoprolol, simvastatin, glyburide, asa
• HR in office 60’s, dropped to 30’s with activity
Which of the following is least
associated with the conduction
disease seen in this patient?
a) Age
b) Use of beta blocker
c) Diabetes
d) Renal insufficiency
e) H/O CAD
EKG 8
71 yo woman • Exertional epigastric discomfort & dyspnea
while walking in Newport. No syncope.
• Old RBBB and LAHB- unchanged
• ECHO & Nuc stress normal 3 mo ago
• BRCA+, s/p hysty & bilat mastect, no XRT
• In ER noted to have transient 2:1 conduction,
this was easily reproduced with walking
• Pacemaker successfully implanted
MRI compatible pacemakers
• Estimated that >50% of pts who receive pacemakers will have some future need for an MRI
• Previous pacemaker patients could not get MRI-wire tips get hot, mess up generator electronic cicuitry
• Currently 1 company (Medtronic, 2/1/11) has an approved MRI compatible device
• In these patients, only MRI’s above neck or below waist are allowed
Atrial Fib/flutter
EKG 9/10 • Afib-irreg, sometimes coarse fib waves, best
seen in V1
• Aflutter- flutter wave rate 250-300, often some
periods of regularity at intervals related to
flutter waves (eg150, 100, 75), Best seen in
inferior leads (2, 3, F)
• Does it matter?- both often warrant anticoag,
flutter may be more challenging to rate
control, flutter much easier to ablate than fib
EKG 11
• Regularization of Atrial Fib
• Progressive conduction disease
• Too much AV slowing meds, may see
junctional escape
– Dig, B-b, Ca-ch-b
– I hate digoxin in old old pts and those with even
mild renal insuf, therapeutic window is too narrow
Which is NOT a sign/symptom
of digoxin toxicity?
a) Nausea
b) Altered vision
c) Bradycardia-afib regularization
d) Ventricular ectopy, salvos of VT
e) ST segment slurring
EKG 12
Final Exam
a) Atrial Fib
b) Atrial Flutter
c) Paroxysmal atrial tachycardia with
block
d) Something else