ECG Recognition and Management: Case Examples. Angela Sims Claire Williams
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1 ECG Recognition and Management: Case Examples Angela Sims Claire Williams
2 Case 1 60 year old man presents to A&E with persistent chest pain for 3 hours
3 What is the most likely diagnosis? A. Acute anterior STEMI B. Pericarditis C. Myocarditis D. Pulmonary embolism E. Acute inferior STEMI
4 Answer E: Acute inferoposterior STEMI
5 Acute anterolateral STEMI
6 Acute STEMI management 999 from home or if presents to primary care Paramedic activation of Primary PCI (PPCI) protocol While awaiting paramedics give aspirin 300mg, clopidogrel 300mg plus s/l GTN
7 Case 2 Asymptomatic 68 yr old man with hypertension and type 2 DM has routine pulse check and ECG with GP
8 What is the most likely diagnosis? A. Atrial fibrillation B. Sinus arrhythmia C. Atrial flutter D. Complete heart block E. Ventricular tachycardia
9 Case 2 Answer C: Atrial flutter
10 Atrial flutter Characteristic sawtooth baseline is more organised than AF: Atrial fibrillation Atrial flutter
11 Atrial flutter Characteristic sawtooth baseline is more organised than AF Requires discussion with patient and risk assessment for anticoagulation (CHADSVasc/HASBLED) Likely kl to require echocardiogram to assess for structural heart disease Consider referral to Cardiologist for cardioversion or ablation
12 Case 3 71 year old man with prior history of CABG collapsed and briefly lost consciousness, BP 76/40mmHg
13 What is the likely diagnosis? A. Atrial fibrillation B. SVT C. Atrial flutter D. Ventricular fibrillation E. Ventricular tachycardia
14 Answer E: Ventricular tachycardia
15 Ventricular tachycardia All regular broadcomplex tachycardias should beconsidered as VTuntil proven otherwise Prior hx of CABG makes this even more likely either scar related or due to background ischaemic cardiomyopathy/acute ischaemia In the acute setting with a hypotensive patient, emergency DC cardioversion under GA is most appropriate Rx Longer term the patient will require an echo +/ angiogram, optimisation of medical therapy and consideration of ICD implant
16 Case 4 55 year old man on amlodipine attends his GP with palpitations for 4 days
17 What is the most likely diagnosis? A. Atrial fibrillation B. Pericarditis C. Atrial flutter D. Wolff Parkinson White syndrome E. Ventricular tachycardia
18 Answer A: Atrial Fibrillation
19 Atrial fibrillation Irregularly irregular narrow complex rhythm/tachycardia, absent P waves Here most likely underlying cause is hypertensive heart disease pt taking amlodipine for hypertension Switch amlodipine to heart rate controlling drug (B blocker or rate controlling calcium antagonist) Assess for stroke prevention thromboprophylaxis C id di l f lf h h l C Consider cardiology referral for rhythm control strategy DC cardioversion +/ ablation if appropriate
20 Fast AF Ventricular rate approx. 140bpm Rate controlled AF Ventricular rate approx. 70bpm
21 Case 5 76 yr old lady attends GP for a medication review. Opportunistic pulse check reveals bradycardia.
22 What is the diagnosis? A. Atrial fibrillation B. Complete heart block C. Atrial flutter D. Second degree heart block E. Sinus bradycardia
23 Answer B: Complete heart block
24 Complete AV dissociation Complete heart block Third degree heart block
25 2:1 heart tblock Complete AV dissociationi Mobitz type two Complete heart block 2nd degree heart block Third degree heart block
26 Complete heart block Bradycardia with norelationship between P wave and QRS activity Aetiology usually conduction system degeneration, but think medications, electrolytes (K + ) or hx compatible with recent ACS Incidental finding more frequently than you may think In most cases will require permanent pacemaker insertion
27 Case 6 16 year old boy admitted to A&E following palpitations associated with loss of consciousness
28 What is the likely diagnosis? A. Atrial fibrillation B. Complete heart block C. Atrial flutter D. Wolff Parkinson White syndrome E. Ventricular tachycardia
29 Answer D: Wolff Parkinson White syndrome
30 Accessory pathways Uncommon (1 3 per 1000) but can be important AV node usually prevents conduction of very rapid rhythms from atria to ventricles Accessory conduction pathway enables conduction to bypass the AV node pre excitation Seen on ECG as short PR interval plus delta wave Enables fast atrial ti rhythms hth to bypass the AV node and conduct directly to the ventricles Fast atrial fibrillation therefore transmitted directly to the ventricles potential cause of cardiac arrest Accessory pathway
31 F B I Fast Broad Irregular FBI = Pre excited AF
32 Any questions?
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