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ECG Master Session SENIOR RESIDENT EDITION

This session features a case study presented by PGY-6 fellows from Boston Medical Center, focusing on a 65-year-old male with a history of hypertension and active smoking. During a routine ECG evaluation, the findings reveal the complexities of diagnosing various cardiac conditions. The discussion includes sinus rhythm interpretation, identification of wide QRS complexes, and the clinical implications of left and right bundle branch blocks (LBBB, RBBB). Fellows will explore diagnostic nuances, treatment considerations, and the significance of ST elevations in the context of acute myocardial infarction (MI).

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ECG Master Session SENIOR RESIDENT EDITION

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  1. ECG Master SessionSENIOR RESIDENT EDITION ShivdaPandey, PGY-6 Mark Villalon, PGY-6 Boston Medical Center Cardiovascular fellows

  2. What is your ECG diagnosis? • PCP Clinic Visit • 65 year old male with PMH hypertension and active smoking is in your clinic for an initial evaluation. • He has no complaints and feels well. • Routine ECG is performed in light of his cardiac risk factors and reveals the following:

  3. What is your diagnosis? • A. I know the diagnosis and can teach this concept to my 3rd year med student • B. I’m pretty sure about this diagnosis • C. I’m not very sure about this diagnosis • D. What does the automated read say?

  4. Diagnosis Step 1: Normal sinus rhythm ** Always start with the rhythm**

  5. “NSR is not “There’s a P before every QRS” • “There’s a P before every QRS” • This does not define NSR • Can be seen in flutter, a-tach etc • Sinus rhythm = Upright P’s in: • Lead I, II and aVF • Right to left activation

  6. Diagnosis • NSR • Wow, is that QRS wide or something?

  7. Sinus rhythm and the wide QRS 100 msec 120 msec • Normal QRS width • IVCD • “Incomplete RBBB” • “Incomplete LBBB” • LBBB • RBBB • IVCD

  8. South Shore Plaza Fast Slow

  9. LBBB: RV contracts, then LV contracts V6 V6

  10. Left Bundle Branch Block • QRS > 120 msec • V5-V6: Broad R wave • I + aVL: Absence of Q wave

  11. RBBB: Left ventricle contracts, then right ventricle contracts • QRS > 120 msec • V1-V2: RSR’ • Lateral leads: Deep terminal S wave

  12. A. IVCD • B. RBBB • C. LBBB

  13. A. IVCD • B. RBBB • C. LBBB

  14. A. IVCD • B. RBBB • C. LBBB

  15. “When I go fast, I go wide” • Rate-related aberrancy • Usually RBBB, but can be LBBB • Refractoriness • Clinical significance: At faster rates, need to differentiate VT vs SVT with aberrancy

  16. PA catheter insertion Pt with LBBB Complete heart block. Hopefully there’s an escape rhythm. Watch the monitor during insertion.

  17. 55M with PMH DM2 and smoking p/w 1hr of “crushing” chest pain. ECG from last week with NSR and normal QRS width. Dx? Mx? • A. New LBBB. Wait for the enzymes. • B. New LBBB. Admit to Obs unit. • C. New LBBB. Call cards fellow to activate the cath lab STAT.

  18. 55M with PMH DM2 and smoking p/w 1hr of “crushing” chest pain. ECG from last week with NSR and normal QRS width. Dx? Mx? • A. Old LBBB. Wait for the enzymes. • B. Old LBBB. Admit to Obs unit. • C. Old LBBB + acute MI. Call cards fellow STAT. • D. This is a trick question.

  19. Discordant:QRS deflection is opposite of T wave deflection Concordant:QRS deflection is the same of T wave deflection Normal in LBBB and paced rhythm

  20. How to diagnose an acute MI in pt with LBBB (or paced rhythm) • ST elevation ≥1 mm in a lead with upward (concordant) QRS complex - 5 points • ST elevation ≥5 mm in a lead with downward (discordant) QRS complex - 2 points • ST depression ≥1 mm in lead V1, V2, or V3 - 3 points • ≥3 points = 90% specificity of STEMI (sensitivity of 36%)

  21. Thank you

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