Topik 6 - ECG in clinical practica (Advanced ECG)

1. ECG In Clinical Practice
Benny M Setiadi
Cardiology and Vascular Medicine Department Sam Ratulangi
University, Prof Dr. RD Kandou General Hospital
Manado, Indonesia

2. CASE 1

3. Clinical Background
• A 65 years old male came to the hospital with the main complaint of
palpitation and shortness of breath for the last 3 hours.
• He has history of hypertension and an active smoker
• General condition : dyspneic and in distress
• Physical Examination : BP 150/90 mmHg, RR 26 x/minutes. Minimal
Wet rales in both lungs. Normal JVP, no hepatomegaly and no edema

5. Discussion
1. What abnormalities do you see in the ECG?
2. What should you do?

6. ANSWER

7. RBBB like pattern, Irregularly irregular rate
with no visible P wave, ST elevation in V1-V3
Dx : Acute Myocardial Infarction + AF with
rapid Ventricular Response

8. What Should You Do?
Urgent Revascularization

9. MI Induced AF
Acute Myocardial Infarction
Atrial
Ischemia
Diastolic
Dysfunction
↑ LVEDP
↑ LA
Pressure
Autonomic
Dysfunction
Neurohormonal
Activation
Inflammation
Atrial Fibrillation
In AMI with AF → Beware of Impending Acute
Lung Oedema

10. CASE 2

11. Clincal Background
• A 56 years old male was admitted to the hospital because of chest
discomfort. Has history of hypertension for 10 years.
• General Condition : In Distress
• Blood Pressure : 110/60mmHg, RR 24 x/mnt, Temperature 36.5 ºC
• Laboratory examination : Not Available yet.

13. Discussion
1. What abnormalities do you see in the ECG?
2. What should you do?

14. ANSWER

15. What abnormalities do you see in the ECG?
Sinus Rhythm. ST depression with tall T wave
V1-V5, ST elevation avR
Dx : de Winter’s T wave

16. What Should You DO?
STEMI→ ST elevation in 2 contiguous leads
STEMI equivalent
New LBBB / RBBB
ST elevation in avR with ST depression in ≥8 leads
Wellen Syndrome
De Winters T wave

17. What Should You DO?
1. Urgent Revascularization

18. CASE 3

19. Clincal Background
• The junior doctor report a patient to you
• A 45 years old male was admitted at the hospital with the main
complaint of chest discomfort.
• Patient had history of hypertension and smoking
• Vital sign and Physical examination is unremarkable.
• Your junior doctor think that the patient has an unstable angina based
on the ECG.

21. Discussion
1. What abnormalities do you see in the ECG?
2. Do you think your junior doctor should receive “Early
ACS Awareness Award?”

22. ANSWER

23. SR 75 x/minute
Poor R progression and QRS from V2 to V6
become smaller

24. • Precordial lead move from RV to LV → Increase QRS Voltage
• When the QRS voltage become smaller, instead of larger:
1. Dextrocardia → Inverted P and QRS in I and avL (Except if
the Left and right precordial lead also misplaced)
2. Lead displacement

25. Discussion
1. What abnormalities do you see in the ECG?
• Suspect Precordial Lead Displacement → Ask for a new ECG

27. Discussion
1. What abnormalities do you see in the ECG?
• Suspect Precordial Lead Displacement → Ask for a new ECG
2. Do you think your junior doctor should receive “Early ACS
Awareness Award?”
• Definitely NOT
• You should teach your resident the correct position of lead placement

28. CASE 4

29. Clincal Background
• The junior doctor report a patient to you
• A 50 years old male was admitted at the hospital with the main
complaint of chest discomfort.
• Patient had history of hypertension and dyslipidemia
• Vital sign and Physical examination is unremarkable.
• Your junior doctor think that the patient has an ACS based on the
ECG.

31. Discussion
1. What abnormalities do you see in the ECG?
2. Do you think this time your junior doctor should receive
“Early ACS Awareness Award?”

32. ANSWER

33. SR 100 x/minute
Slight ST/T changes in limb lead
Almost Exactly the same QRS in lead II, III, avF
Almost exactly the same QRS in avR and avL

34. Flat QRS in lead I
Almost Identical QRS
in II, III, avF
Almost Identical QRS
in avL and avR
Bilateral Arm-Leg
Reversal

35. Correct Lead Placement
Bilateral Arm-Leg
Reversal

36. Discussion
1. What abnormalities do you see in the ECG?
• Suspect Bilateral Arm-Leg Reversal → Ask for a new ECG

38. Discussion
1. What abnormalities do you see in the ECG?
• Suspect Bilateral Arm-Leg Reversal→ Ask for a new ECG
2. Do you think your junior doctor should receive “Early ACS
Awareness Award?”
• Definitely NOT, Maybe you should consider giving him/her a
“Clumsiness Award” for putting wrong lead placement twice in a row
• You should work harder to teach your doctor the correct position of
lead placement

39. CASE 5

40. Clincal Background
• The junior doctor report a patient to you
• A 52years old male was admitted at the hospital with the main
complaint of chest discomfort and diaphoresis.
• Patient had history of hypertension, smoking and dyslipidemia
• Vital sign and Physical examination is unremarkable.
• Your junior resident think that the patient has an ACS based on the
ECG.

42. Discussion
1. What abnormalities do you see in the ECG?
2. Do you think this time your junior doctor should receive
“Early ACS Awareness Award?”

43. ANSWER

44. SR 75 x/minute
Subtle ST elevation (0.02-0.05 mV) in II, III, avF
Subtle ST Depression in I and avL

45. Discussion
Guideline → ST elevation at least 1mm in limb lead → STEMI
The degree of ST elevation influenced by the amplitude of QRS
Changes in Reciprocal Lead will help to established diagnosis
Subtle ECG changes especially in typical symptoms or high risk patient
should always alert awareness

46. Discussion
1. What abnormalities do you see in the ECG?
• Suspect STEMI Inferior → Treat ACS, Prepare for PCI, Closed
Observation

47. ECG 24 minutes after the first
PCI → Diffuse CAD with 99% stenosis in LCX

48. Discussion
1. What abnormalities do you see in the ECG?
• STEMI Inferior
2. Do you think your junior doctor should receive “Early ACS
Awareness Award?”
• You know what they say → “Third time is a charm”
• He/she definitely deserve “Early ACS Awareness Award” this time.

49. CASE 6

50. • A 51 years old female with the main complaint of a subtle atypical
chest discomfort and epigastric pain.
• History of hypertension and ESRD with routine haemodialysis twice a
week (Last HD 2 days earlier)
• Physical examination was unremarkable.

52. 1. What is your expertise on the ECG?
2. What will you do?

53. ANSWER

55. What Should You DO?
Hyperkalemia
Increase IKR Function
Rapid Repolarization
Tall T wave
Studies → tall T wave, T wave amplitude, and T/R ratio poorly correlated to the
potassium level, in Renal disease patient

56. In This ECG → T wave amplitude 0.45 mV with T/R ratio 0.3,
T wave duration 160 ms
What Should You DO?
In case of suspicion, especially in high risk patient → Always check
laboratory examination
Kalium = 7.2 in this patient
Urgent hemodialysis

57. T wave duration 240 ms. No changes in T wave
amplitude and T/R ratio

60. CASE 7

61. Clincal Background
• A 40 years old male was admitted to the hospital with the main
complaint of nausea, vomiting and abdominal pain for several hour.
• He had history of hypertension and dyslipidemia.
• BP : 140/90 mmHg, HR : 170 x/min, RR: 26 x/min
• Physical Examination Unremarkable

63. Discussion
1. What abnormalities do you see in the ECG?
2. What should you do?

64. ANSWER

65. Narrow Complex Tachycardia
ST elevation in II, III, avF, V4-V6

66. Discussion
ST elevation in II, III, avF and V4-V6 → However no reciprocal changes noted
The extremely fast Ventricular Rate is rare in STEMI without cardiogenic shock
P wave is completely upright in V1 → rare in normal heart
Search for arrhythmia induced mimicking ST elevation or secondary cause of ST
elevation (bleeding, sepsis, dehydration, PE)

67. Atrial Flutter 2 : 1

68. Discussion
1. What abnormalities do you see in the ECG?
• Atrial Flutter 2:1
2. What should you do?
• Vagal maneuver or AV node blockage to make sure “false” ST
elevation.
• Search secondary cause of Atrial flutter and patient’s
symptoms

69. ECG during diltiazem infusion → Confirming
“false” ST elevation

70. CASE 8

71. Clincal Background
• A 30 years old female was admitted to the hospital with the main
complaint of chest pain.
• Physical Examination Unremarkable

73. Discussion
1. What abnormalities do you see in the ECG?
2. What should you do?

74. ANSWER

75. Seemingly Normal ECG
However the T wave in lead V4 taller than QRS
In addition, very subtle ST elevation (0.05-0.1 mV) in I, avL, V1,V2,V3

76. Discussion
The T wave in lead V4-V6 should be far less than QRS wave, let alone taller
In patients with early repolarization, the relatively tall T wave almost
always accompanied with tall QRS voltage
Suspect Hyperacute T wave

77. Discussion
1. What abnormalities do you see in the ECG?
• Suspect hyperacute T wave
2. What should you do?
• ACS treatment.
• Closed observation

78. ECG at 20 minutes

79. ECG at 40 minutes

80. ECG at 60 minutes
PCI → LAD Occlusion

81. Our patients is human being,… Not the Paper
Same ECG in Different Patient can yield
Different Cause, Different Diagnosis and
Different Treatment
Complete Understanding in Your Patient
Condition and ECG can Guide Your Treatment

83. Thank You