Devender N. Akula, MD, FACC Cardiac Electrophysiologist Lourdes Cardiology
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Normal Sinus Rhythm
Normal Sinus Rhythm
Case 1 63 year old male with history of hypertension is in your office to establish care as a new patient. Has no cardiac symptoms. Vague headache. Meds: metoprolol 50 mg BID BP 148/86 Exam: Unremarkable ECG
Case 1
Case 1 A. Send him to the emergency room B. Stop his metoprolol C. Order cardiac stress test D. Order TSH E. Arrange routine cardiology follow up
Normal Sinus Rhythm Left Bundle Branch Block
Left Bundle Branch Block LBBB has no prognostic significance in patients without structural heart disease. Arrange for a routine cardiology consult.
Left Bundle Branch Block Right Bundle Branch Block
Case 2 18 year old female comes with complaints of syncope which happened after vigorous exercise in hot weather. She has prior history of brief palpitations and dizziness that has being attributed to anxiety. Meds : none BP 112/70 No family history of sudden cardiac death ECG
Case 2
Case 2 A. Advise her to drink plenty of fluids before exercise B. Arrange for Tilt Table Test C. Ask for her records from her pediatrician and arrange follow up in 1 week D. Order MRI / MRA of the brain E. Send her to the emergency room
Wolf White Parkinson (WPW) ECG
Case 2 WPW with atrial fibrillation Ventricular Arrhythmia
Case 2 She should be sent to the emergency room
Case 3 82 year old male with history of CAD, prior myocardial infarction, normal left ventricular function is in your office as he had been having dyspnea on exertion and near syncopal spells. BP 94/58, HR 42 bpm Meds: Metoprolol 100 mg daily, Aspirin 325 mg daily, Atrovastatin 40 mg daily, Amlodipine 5 mg daily ECG
Case 3
Case 3 A. Send him to emergency room B. Stop his metoprolol and ask him to come back in 48 hours for follow up C. Add midodrine for his low blood pressure D. Give intravenous atropine in office, add midodrine and arrange for 48 hours follow up
Complete Heart Block
Complete Heart Block He should be sent to the emergency room via ambulance
Case 4 73 year old female with history of anterior myocardial infarction 10 years ago, hypertension, diabetes comes with complains of feeling very tired and exertional dyspnea. BP 102/54 Meds: Aspirin 81 mg daily; Carvedilol 12.5 mg bid; Pravastatin 80 mg daily; Lisinopril 20 mg daily and metformin 1000 mg daily ECG
Case 4
Case 4 A. Give IV adenosine 12 mg to stop tachycardia B. Try vagal maneuvers / carotid sinus massage to slow or stop tachycardia C. Call EMS and send him to emergency room D. Give IV metoprolol 5 mg slowly over 5 min E. Arrange for outpatient cardiology consultation
Ventricular tachycardia
Case 4 Normal sinus rhythm Ventricular tachycardia
Case 4 Send her to the emergency room with ambulance
Recap LBBB is a benign finding in someone with no structural heart disease Someone with WPW ECG pattern and syncope needs cardiac work up Complete heart block will not improve by merely stopping betablockers (AV node blocking medications) Wide complex tachycardia, irrespective of symptoms, should be treated as ventricular tachycardia (90%) in patients with known myocardial infarction.
Case 5 55 year old female with history of obstructive sleep apnea, obesity, hypertension, hyperlipidemia and diabetes comes to your office for routine follow up. She states that she has been doing well and complaint with her CPAP. Meds: Aspirin 81 mg daily; Pravastatin 80 mg daily; Lisinopril 20 mg daily and metformin 1000 mg daily BP 156/92 ECG
Case 5
Case 5 A. Send patient to emergency room B. Start patient on anticoagulation C. Order routine cardiology consult as outpatient D. Order a stress test E. Get annoyed with your nurse for doing EKG without telling you
Atrial flutter
Case 5 Normal Sinus rhythm Atrial Flutter
Case 5 Atrial flutter Atrial Fibrillation
CHA DS Vasc Score Case 5 2 2 Congestive heart failure - 1 Hypertension - 1 Age 65 74 years - 1 Age >/= 75 years - 2 Diabetes - 1 Female Gender - 1 Stroke (TIA, CVA, thromboembolism) - 2 Vascular disease - 1
Case 5 Start patient on anticoagulation CHADS Vasc score 3
Case 6 63 year old patient of yours had successful cardioversion for persistent atrial fibrillation in the hospital was sent home on sotalol 160 mg bid and dabigatran 150 mg bid. He states that he felt great since cardioversion but in the last two days has been having several near syncopal episodes. BP 128/70 ECG
Case 6
Case 6 A. Tell your technician to repeat ECG as there is too much artifact B. Shock him with AED C. Order blood work BMP, Magnesium, TSH and see him back in one week D. Send him to the emergency room E. Set up routine cardiology follow up
Torsades with QT prolongation
Torsades with QT prolongation Understand that sotalol can cause QT prolongation and torsades; which can lead to sudden cardiac death.
Case 7 71 year old patient of yours comes with complains of severe left jaw pain for last 48 hours and vague chest discomfort. She denies any fevers. She has history of hypertension, peripheral vascular disease and diabetes. She has tried Tylenol and ibuprofen without relief of pain. BP 154/94 Meds: Aspirin 81 mg daily; Carvedilol 12.5 mg bid; Pravastatin 80 mg daily; Lisinopril 20 mg daily and metformin 1000 mg daily Your technician does ECG before you see the patient
Case 6
Old ECG 1 year ago Case 7
Case 7 A. Give her a prescription for tramadol and reassess in 48 hours B. Place her on antibiotics for tooth infection C. Send her to emergency room D. Send her to the dentist next door for urgent evaluation E. Send her for X-rays of her jaw / teeth on left side
New LBBB
Case 7 Recognize that new Left bundle branch block associated with chest pain / chest pain equivalent is suggestive of myocardial ischemia or infarction She should be sent to the emergency room.
Case 7
Case 8 As you are leaving the hospital after a hectic weekend rounds, nurse taking care of your patient comes panicking with the following strip He is a 76 year old male with remote history of CABG, Hypertension and diabetes who had undergone emergent cholecystectomy. He is post op day 2. BP 134/78 He was sitting in the bed watching TV when this event happened.
Case 8
Case 8 A. Get annoyed with the nurse for making your day long B. Have patient transferred to CCU immediately, call stat cardiology consult C. Start IV amiodarone immediately D. Reassure the nurse and the patient that it is a benign condition E. Order stat electrolytes and troponin
Artifact
Case 8 Recognize artifact Reassure nurse and patient
Case 9 54 year old male who returned from vacation from Mexico 2 weeks ago comes with complaints of severe chest pain, which is worse with deep breath and shortness of breath. No major medical problems. There is family history of coronary artery disease. Meds: none BP 138/70
Case 9
Case 9 A. Call EMS send him to emergency room B. Start him on aspirin and beta-blockers, arrange outpatient cardiac follow up C. Give him high dose ibuprofen and reassess in 10 days D. Start him on prednisone 40 mg daily tapering dose E. Start him on oral doxycycline 7 day course
Pericarditis
Case 9 Pericarditis Acute Myocardial Infarction
Case 9 Start him on ibuprofen
Recap Identify and manage atrial flutter / atrial fibrillation Long QT and ventricular arrhythmias associated with sotalol Significance of new LBBB in patient with ongoing chest pain Identify artifact Identify pericarditis ECG pattern
Primary Care Physicians & Cardiologists
Hyperkalemia
Mobitz type 1 AV block Wenckebach AV block
Mobitz type 2 AV block