CardioNerds ECG Challenge #7

Question:

53 yo Italian F with COPD after eating too much ribollita​

Question:
What accounts for the ST segment abnormalities seen in 2, 3 and aVF

Answer

Atrial repolarization (Ta wave) from right atrial enlargement accounts for these repolarization changes in 2, 3 and aVF. ​

Learning Points

The P wave axis is 75⁰, rightward shifted and at the upper limit to be called sinus.  The heart rate is 94.  The peaked P waves in leads 2, 3 and aVF all exceed 3 mm in height and the P waves in V1 and V2 are entirely upright and exceed 1.5 mm.  In leads 2, 3 and aVF, where the P waves are largest, atrial repolarization is evident as a negative deflection (Ta wave) in the respective ST segment of 2, 3 and aVF (see blue arrows).  These ST segment abnormalities are due to right atrial enlargement and are not ST segment abnormalities of ventricular origin (1,2).​

Show Answer

Powered by EKGaction: EKGaction is much more than the usual textbook of EKG and is different from other online programs.  It teaches/reinforces EKG interpretation skills using a method that integrates clinical pearls that makes it easier to commit to memory.  These pearls accompany every case and are called Learning Points and Collateral Tracings.  The multiple indexes make it useful as a reference. It has been perfected over 15 years, teaching at leading cardiology fellowship programs.  It has been shown to improve performance on board exams and it’s fun to use!

Learn more at https://www.ekgaction.com/

References:​
1. Surawicz B and TK Knilans. Chou’s Electrocardiography in Clinical Practice, 6th Edition. 2008; Philadelphia. Saunders Elsevier. Pp 42-3 and 240. Addresses how this ST change​
can give spurious results for inferior wall ischemia.​
2. Schiavone W. EKGaction.com 2019; Supplemental case 86 for Ta wave (LAE) and Supplemental case 87 for Ta wave (RAE).​

CardioNerds ECG Challenge #6

Question:

46 yo M is 2 days S/P minimally-invasive mitral valve repair.

Why is he complaining of intermittent neck discomfort❓

Answer

Intermittent cannon A waves account for the intermittent neck discomfort.

Learning Points:

  1. The atrial rhythm is sinus at 81/min.​
  2. The QRS complexes are accelerated junctional at 79/min, a common arrhythmia following heart surgery.​
  3. There is A-V dissociation.​
  4. When the PR interval is particularly short or the P wave follows the QRS (not seen in this tracing) the atria contract coincident with, or after the closure of the atrioventricular valves.  The resultant retrograde atrial propulsion of blood into the valveless SVC causes a pronounced pulsation in the neck veins, called a cannon A wave, that he sensed as neck discomfort.  These cannon A waves come in volleys and then disappear, only to return, until the A-V rhythm associates.​
  5. Although acute pericarditis is present and can cause discomfort, this is not intermittent neck discomfort.

Show Answer

Powered by EKGaction: EKGaction is much more than the usual textbook of EKG and is different from other online programs.  It teaches/reinforces EKG interpretation skills using a method that integrates clinical pearls that makes it easier to commit to memory.  These pearls accompany every case and are called Learning Points and Collateral Tracings.  The multiple indexes make it useful as a reference. It has been perfected over 15 years, teaching at leading cardiology fellowship programs.  It has been shown to improve performance on board exams and it’s fun to use!

Learn more at https://www.ekgaction.com/

CardioNerds ECG Challenge #5

Question:

16 year-old Saudi Arabian boy presents with dyspnea, weakness and heart failure. He was born with a normal heart and has no history of trauma.​

Can you interpret this ECG

Answer

  1. Sinus bradycardia at 56/min​
  2. RA abnormality/enlargement​
  3. LA abnormality/enlargement​
  4. AV block, 1⁰​
  5. Right axis deviation (+127⁰)​
  6. Right ventricular hypertrophy

This is rheumatic heart disease. The primary valve lesion was mitral stenosis which resulted in massive left atrial enlargement, pulmonary hypertension, right ventricular hypertrophy, right atrial enlargement and heart failure, first left, then right.  While having a tall R wave in V1 is the most common EKG pattern for RVH, in young patients with mitral stenosis like presented here, RVH can be diagnosed on the basis of right axis deviation and posterior axis deviation with poor R wave progression and large S waves in the lateral precordial leads.​

Show Answer

Powered by EKGaction: EKGaction is much more than the usual textbook of EKG and is different from other online programs.  It teaches/reinforces EKG interpretation skills using a method that integrates clinical pearls that makes it easier to commit to memory.  These pearls accompany every case and are called Learning Points and Collateral Tracings.  The multiple indexes make it useful as a reference. It has been perfected over 15 years, teaching at leading cardiology fellowship programs.  It has been shown to improve performance on board exams and it’s fun to use!

Learn more at https://www.ekgaction.com/

CardioNerds ECG Challenge #4

Question:

56 year-old woman presents to the local ED frightened.  She has a history of anxiety and is on no medications.​
Interpret this EKG

Answer

1. Sinus tachycardia at 107/min​
2. Incorrect electrode placement, specifically RA/LA transposition​
3. Otherwise normal EKG

Learning Points:​

Fright accounts for her sinus tachycardia. With RA/LA transposition lead I is inverted, lead II looks like lead III, aVR like aVL, aVL like aVR, aVF and V1-V6 are unchanged. This arm lead transposition does not account for QRS voltage in V3-V6 which is due to breast attenuation. The R/S ratio increasing from V1-V6 is one clue that this is not dextrocardia.

Show Answer

Powered by EKGaction: EKGaction is much more than the usual textbook of EKG and is different from other online programs.  It teaches/reinforces EKG interpretation skills using a method that integrates clinical pearls that makes it easier to commit to memory.  These pearls accompany every case and are called Learning Points and Collateral Tracings.  The multiple indexes make it useful as a reference. It has been perfected over 15 years, teaching at leading cardiology fellowship programs.  It has been shown to improve performance on board exams and it’s fun to use!

Learn more at https://www.ekgaction.com/

CardioNerds ECG Challenge #3

Question:

87 yo M who is 2 days S/P TAVR;  What is the complete interpretation of this EKG?

Answer

  1. Sinus rhythm at 94/min​
  2. Accelerated junctional rhythm at 72/min​
  3. AV dissociation​
  4. AV block, 3⁰​
  5. Left axis deviation (>-30⁰)​
  6. Left ventricular hypertrophy with secondary repolarization abnormality

Learning points:

Atrioventricular dissociation is a nonspecific term that merely indicates that the atrial and ventricular rates are different. Complete AV block (AV block 3⁰) exists when the atrial rate is faster than the ventricular, the rates are constant, and there is no relationship between atrial and ventricular events.  In this EKG both AV dissociation and AV block 3⁰ pertain.  However, the escape mechanism is from the AV junction at a rate of 72/min and the cardiac output is preserved better than if the escape mechanism were ventricular at a rate in the 40’s.  The decision regarding the need for a permanent pacemaker could be delayed.​

Show Answer

Powered by EKGaction: EKGaction is much more than the usual textbook of EKG and is different from other online programs.  It teaches/reinforces EKG interpretation skills using a method that integrates clinical pearls that makes it easier to commit to memory.  These pearls accompany every case and are called Learning Points and Collateral Tracings.  The multiple indexes make it useful as a reference. It has been perfected over 15 years, teaching at leading cardiology fellowship programs.  It has been shown to improve performance on board exams and it’s fun to use!

Learn more at https://www.ekgaction.com/

CardioNerds ECG Challenge #2

Question:

67 year-old man status post ablation for atrial fibrillation presents with this ECG​

  1. Is the 9th P wave premature?
  2. What accounts for the PR prolongation?

Answer

  1. No. The 9th P wave is not premature.​
  2. Concealed Conduction accounts for the PR prolongation.

As seen best in rhythm strip V1, all of the P waves on this tracing are equidistant and are sinus beats according to the P wave axis. The VPC that precedes the 9th P wave retrograde conducts across the AV node.  While it is not sufficient to block forward conduction of the next sinus beat, it does prolong the ensuing PR interval.​

Show Answer

Powered by EKGaction: EKGaction is much more than the usual textbook of EKG and is different from other online programs.  It teaches/reinforces EKG interpretation skills using a method that integrates clinical pearls that makes it easier to commit to memory.  These pearls accompany every case and are called Learning Points and Collateral Tracings.  The multiple indexes make it useful as a reference. It has been perfected over 15 years, teaching at leading cardiology fellowship programs.  It has been shown to improve performance on board exams and it’s fun to use!

Learn more at https://www.ekgaction.com/

CardioNerds ECG Challenge #1

Question:

You see this 58 year old man with ischemic cardiomyopathy in clinic.

What’s the rhythm❓

Answer

  1. Atrial Tachycardia with VPCs
  2. A-sense V-pace
  3. 3:2 AV Wenckebach

What’s Mode Switching?

The rhythm is atrial tachycardia at 143/min with VPCs, atrial sensing and ventricular pacing with 3:2 AV Wenckebach periodicity.  The mean V rate is 101/min.  The hallmark of Wenckebach is grouped beating.​

With the exception of the 2 VPCs there is grouped beating displayed as 2 paced beats and a pause, repetitively.  Since the P wave axis is abnormal (equivocal in lead II) and every P wave is equidistant and the P wave to ventricular paced interval prolongs until the 3rd P wave does not have a ventricular paced beat following it, this atrial rate exceeds the upper rate of the pacemaker as it is programmed.  The pacemaker is programmed to have Wenckebach A sensing and V pacing until the atrial rate slows.  This is different from mode switching that can be enabled to activate when atrial fibrillation or atrial flutter is encountered.  During mode switching atrial sensing is turned off and the pacing mode is VVI.  It is best not to allow the V pacing rate to be so high when the patient has ischemic cardiomyopathy.

Show Answer

Powered by EKGaction: EKGaction is much more than the usual textbook of EKG and is different from other online programs.  It teaches/reinforces EKG interpretation skills using a method that integrates clinical pearls that makes it easier to commit to memory.  These pearls accompany every case and are called Learning Points and Collateral Tracings.  The multiple indexes make it useful as a reference. It has been perfected over 15 years, teaching at leading cardiology fellowship programs.  It has been shown to improve performance on board exams and it’s fun to use!

Learn more at https://www.ekgaction.com/