A great tutorial from Dr Alistair Jones NHS medical educator (http://www.yorkshiremedicaleducation.co.uk/about-us) on ECG syndromes. Beyond the basics (but essential knowledge for training emergency physicians)

1. Alastair Jones
ADVANCED ECGs
Beyond the basics…

2. Quiz Q1
✤ 55 year old man presents with central crushing chest pain.
✤ Comment on the ECG and what is you treatment plan?

3. Quiz Q1

4. Quiz Q2
✤ 78 year old diabetic man. Previous MI. Presents with sudden onset
SOB and an odd feeling in chest.
✤ Comment on the ECG and what is you treatment plan?

5. Quiz Q2

6. Quiz Q3
✤ 45 year old male. Brought in by wife after an episode of severe
indigestion last night. Now symptoms free. Insists he’s fine and wants
to go home. Thinks his wife is worrying unnecessarily.
✤ Obs fine. Bloods normal. Trop negative.
✤ Comment on the ECG and what is your management plan?

7. Quiz Q3

8. Quiz Q4
✤ 78 year old lady who presents with ischaemic chest pain.
✤ Comment on the ECG.
✤ How can you confirm your diagnosis and what is your management
plan?

9. Quiz Q4

10. Quiz Q5
✤ 20 year old student. Brought in after collapse.
✤ Went to feel lightheaded and then blacked out for a few seconds.
✤ Not happened before. Now feels fine and wants to go home.
✤ Comment on his ECG and what would you tell him?

11. Quiz Q5

12. Quiz Q6
✤ VT OR SVT?

13. Quiz Q6

14. Elevation in aVR

15. Elevation in aVR
✤ Single lead - significant?
✤ Yes. STE in aVR implies lesion of the left main coronary artery

16. Elevation in aVR
✤ STE in aVR itself of more than 1.5 mm carries a 75% specificity of
LMCA and ~75% mortality!
✤ STE in aVR + avL -- 90% specificity AMI
✤ STE in aVR + V1 -- suggestive either prox LAD or LMCA occlusion but
✤ STE in aVR > V1 -- more suggestive of LMCA
✤ The significance of STE in aVR is dubious in the presence of BBB.

17. Sgarbossa Criteria
✤ Or how to detect AMI in LBBB
✤ ST elevation ≥1 mm in a lead with upward (concordant) QRS
complex - 5 points
✤ ST depression ≥1 mm in lead V1, V2, or V3 (concordant) - 3
points
✤ ST elevation ≥5 mm in a lead with downward (discordant) QRS
complex - 2 points
✤ ≥3 points = specificity of 98% and sensitivity of 20% (10 paper
meta-analysis of 614 patients)

18. Sgarbossa Criteria

19. Sgarbossa Criteria
✤ Only one lead required BUT the significance of elevation in aVR is no
longer certain.
✤ Serial / old ECG’s can also help

20. Wellens’ Syndrome
✤ Wellens’ syndrome is a pattern of inverted or biphasic T waves in V2-3
(in patients presenting with ischaemic chest pain) that is highly
specific for critical stenosis of the left anterior descending artery.
✤ Patients may be pain free by the time the ECG is taken and have
normally or minimally elevated cardiac enzymes; however, they are
at extremely high risk for extensive anterior wall MI within the next 2-3
weeks.
✤ Type 1 Wellens’ T-waves are deeply and symmetrically inverted
✤ Type 2 Wellens’ T-waves are biphasic, with the initial deflection
positive and the terminal deflection negative

21. Wellens’ Syndrome - Type 1

22. Wellens’ Syndrome - Type 2

23. Wellen’s Syndrome
✤ Wellen's criteria is not dependent on ST changes, just the T inversion!
✤ VERY worrying...Signifies critical LAD stenosis!
✤ 100% of 180 patients with the pattern having >50% stenosis of the left
anterior descending coronary artery (mean = 85%), with complete or near
complete occlusion in almost 60%.
✤ Likely to need a cath lab rather than medical therapy...
✤ Should be investigated urgently even if now asymptomatic!
✤ BUT - young children and especially female up to 40 years, may have
normal variant of T inversion (the juvenile pattern).

24. Posterior MI

25. Posterior MI
✤ Be wary in any patient with infero-lateral ischaemia.
✤ Posterior MI is suggested by the following changes in V1-3:
✤ Horizontal ST depression
✤ Tall, broad R waves (>30ms)
✤ Upright T waves
✤ Dominant R wave (R/S ratio > 1) in V2

26. Posterior MI
✤ Posterior Leads:
✤ V7 – Left posterior axillary line, in the same horizontal plane as V6.
✤ V8 – Tip of the left scapula, in the same horizontal plane as V6.
✤ V9 – Left paraspinal region, in the same horizontal plane as V6.

27. Posterior MI

28. Posterior MI
✤ The degree of ST elevation seen in V7-9 is typically modest – note
that only 0.5 mm of ST elevation is required to make the diagnosis of
posterior MI!

29. Posterior MI

30. Posterior MI

31. Brugada Syndrome
✤ 25 year old Asian male has had a collapse. Now feels fine and wants
to go home...

32. Brugada Syndrome
✤ Brugada syndrome is an ECG abnormality with a high incidence of
sudden cardiac death in structurally normal hearts...
✤ Sodium channel mutation (at least 60 different types described so far)
✤ Diagnosis depends upon ECG criteria (which may be transient and
clinical criteria (VF, VT, syncope, FHx sudden cardiac death <45)
✤ Definitive treatment = ICD

33. Brugada Syndrome
✤ May be unmasked / augmented by the following:
✤ Fever
✤ Ischaemia
✤ Multiple Drugs: Sodium channel blockers (eg Flecainide, Propafenone),
Calcium channel blockers, Alpha agonists, Beta Blockers, Nitrates, Cholinergic
stimulation, Cocaine, Alcohol
✤ Hypokalaemia
✤ Hypothermia
✤ Post DC cardioversion

34. Brugada Syndrome - Type 1
Type 1: Coved ST segment elevation >2mm in >1 of V1-V3 followed by a
negative T wave (don’t confuse with RBBB which should have ST
depression)

35. Brugada Syndrome - Type 2
Type 2 has >2mm of saddleback shaped ST
elevation.

36. Brugada Syndrome - Type 3
Brugada type 3 can have either type 1 or type 2 morphology, but with <2mm
of ST segment elevation.

37. Brugada Syndrome
✤ Do they need admitting?
✤ Type 1 ECG and symptomatic = YES!
✤ If undiagnosed - 10% mortality per year...
✤ Asymptomatic patients with a type 1 ECG pattern and all type 2 + 3
ECG patterns can probably go home and have outpatient
electrophysiology...

38. Brugada Syndrome
✤ ...however, EPS is far from a gold standard, with a negative predictive
value of less than 50% and some studies suggest that we might be
getting a little over-excited about this relatively recently described
ECG finding (1992).
✤ One study followed 98 asymptomatic japanese patients with a type 1
ECG found incidentally for 7.8 years and found them to have no
greater mortality than the rest of a 14000 strong cohort. This
highlights the importance of the clinical criteria required for diagnosis
listed above.

39. Trifasicular block
✤ Disease in all 3 conduction fasicles (RBB, LAF, LPF)
✤ May be complete or incomplete:
✤ Incomplete (or Impending) – RBBB, LAD, 1st degree HB
✤ Complete – 3rd degree HB and bifasicular block (usually RBBB and
LAD)

40. Trifasicular block (incomplete)

41. Trifasicular block
✤ Incomplete trifascicular block may progress to complete heart
block.
✤ Patients who present with a syncopal episode and have an
ECG showing incomplete trifascicular block should be
admitted for a cardiology review as they may be having
episodes of complete heart block. Therefore, some of these
patients will require a pacemaker.

42. VT or SVT with aberrant
conduction???

43. VT or SVT with aberrant
conduction???
✤ 3 possibilities:
✤ VT
✤ SVT with aberrant conduction due to bundle branch block
✤ SVT with aberrant conduction due to the Wolff-Parkinson-White
syndrome

44. VT or SVT with aberrant
conduction???
✤ While it is not always possible to differentiate VT from SVT with
aberrant conduction it is important to try. SVT is amenable to AV nodal
blockers. But someone in VT can suffer haemodynamic collapse if AV
blockers given...
✤ Unfortunately, the electrocardiographic differentiation of VT from SVT
with aberrancy is not always possible. However, there are several
electrocardiographic features that increase the likelihood of VT:

45. More likely to be VT...
✤ Absence of typical RBBB or LBBB morphology
✤ Extreme axis deviation (“northwest axis”)
✤ Very broad complexes (>160ms)
✤ AV dissociation (P and QRS complexes at different rates)

46. More likely to be VT...
✤ Capture beats — occur when the sinoatrial node transiently ‘captures’
the ventricles, in the midst of AV dissociation, to produce a QRS
complex of normal duration.
✤ Fusion beats — occur when a sinus and ventricular beat coincides to
produce a hybrid complex.

47. More likely to be VT...
✤ Brugada’s sign – The distance from the onset of the QRS complex to
the nadir of the S-wave is > 100ms
✤ Josephson’s sign – Notching near the nadir of the S-wave

48. More likely to be VT...
✤ Positive or negative concordance throughout the chest leads, i.e.
leads V1-6 show entirely positive (R) or entirely negative (QS)
complexes, with no RS complexes seen.
✤ RSR’ complexes with a taller left rabbit ear. This is the most specific
finding in favour of VT. This is in contrast to RBBB, where the right
rabbit ear is taller.
VT
RBB
B

49. The likelihood of VT is also
increased if:
✤ Age > 35 (positive predictive value of 85%)
✤ Structural heart disease
✤ Ischaemic heart disease
✤ Previous MI
✤ Congestive heart failure
✤ Cardiomyopathy
✤ Family history of sudden cardiac death (suggesting conditions such as HOCM,
congenital long QT syndrome, Brugada syndrome or arrhythmogenic right
ventricular dysplasia that are associated with episodes of VT)

50. The likelihood of SVT with
aberrancy is increased if:
✤ Previous ECGs show a bundle branch block pattern with identical
morphology to the broad complex tachycardia.
✤ Previous ECGs show evidence of WPW (short PR < 120ms, broad
QRS, delta wave).
✤ The patient has a history of paroxysmal tachycardias that have been
successfully terminated with adenosine or vagal manoeuvres.
✤ HOWEVER - IF IN DOUBT TREAT AS VT

51. Quiz Answers Q1
✤ 55 year old man presents with central crushing chest pain.
✤ Comment on the ECG and what is you treatment plan?

52. Quiz Answers Q1

53. Quiz Answers Q1
✤ NSR
✤ Widespread ST depression
✤ Elevation in aVR --> LMCA lesion!!
✤ D/W Papworth for ?PPCI, ACS Rx etc…

54. Quiz Answers Q2
✤ 78 year old diabetic man. Previous MI. Presents with sudden onset
SOB and an odd feeling in chest.
✤ Comment on the ECG and what is you treatment plan?

55. Quiz Answers Q2

56. Quiz Answers Q2
✤ Paced rhythm - Broad complexes
✤ Positive Scarbossa Criteria
✤ > 5mm ST elevation in III, aVF
✤ < 1mm ST depression V2, V3
✤ 1mm ST elevation aVL
✤ Needs PPCI

57. Quiz Answers Q3
✤ 45 year old male. Brought in by wife after an episode of severe
indigestion last night. Now symptoms free. Insists he’s fine and wants
to go home. Thinks his wife is worrying unnecessarily.
✤ Obs fine. Bloods normal. Trop 12.
✤ Comment on the ECG and what is your management plan?

58. Quiz Answers Q3

59. Quiz Answers Q3
✤ Wellens’ type 1 - deep symmetrical TWI anteriorly.
✤ Likely has a severe LAD stenosis and should be investigated urgently.
✤ Refer medics for urgent angiography.

60. Quiz Answers Q4
✤ 78 year old lady who presents with ischaemic chest pain.
✤ Comment on the ECG.
✤ How can you confirm your diagnosis and what is your management
plan?

61. Quiz Answers Q4

62. Quiz Answers Q4
✤ Likely posterior MI (borderline inferior MI also)
✤ Anterior ST depression with a dominant R wave.
✤ Confirm with posterior leads
✤ Treat as per AMI - PPCI

63. Quiz Answers Q5
✤ 20 year old student. Brought in after collapse.
✤ Went to feel lightheaded and then blacked out for a few seconds.
✤ Not happened before. Now feels fine and wants to go home.
✤ Comment on his ECG and what would you tell him?

64. Quiz Answers Q5

65. Quiz Answers Q5
✤ Brugada syndrome type 1
✤ Risk of sudden death. Need admission for an ICD...

66. Quiz Answers Q6
✤ VT OR SVT?

67. Quiz Answers Q6

68. Quiz Answers Q6
✤ Probably SVT with aberrant conduction.