Chapters Transcript Video 10 ECGs Every Primary Care Provider Should Recognize Back to Symposium Click Here to View Presentation Deck We're gonna go through 10 EKGs together. My goal for you all is get out the nice red pens Amy's put for each of you, and you're gonna write in about 15 seconds, your interpretation of that EKG and then we're gonna look at it. The other day we were cleaning out our closets and we found my old uh flip phone from 2005, and my kids thought it looked prehistoric. That's 2005. The first EKGs were done in the late 1800s. William Eindhoven in the early 1900s had a 600 pound machine that was what was used to do these. These are still incredibly relevant. Each of us will tell you every night we're looking at these studies. For me as an interventional cardiologist, the, the calls I get at night are to look at EKGs suggesting we need to rush someone to the cath lab and do an intervention. We've got a medical audience here. I would say for those of us that that participate in sort of um peer review and medical malpractice reviews, EKGs are probably one of the most common reasons that one of us gets in the line of fire is because reading these EKGs, there's a lot of information there it can be hard to pick it up. So I think this is relevant to everyone in this audience. So EKG number one, you guys are writing as I'm talking about this stuff. I want you to to to look at that EKG with each of these what we're looking at is the rate. The rhythm. The conduction pattern, and the presence or absence of other abnormalities of intervals like, you know, ST wave changes, T wave changes, looking for heart attacks, looking for problems like that. So number one is going to be easy. I'm not going to belabor the point. Number one is easy in that it's actually a very normal EKG. The rate's a little bit low. You could say this is a sinus rhythm, a sinus bradycardia at a rate of 45 beats per minute. The reason I include this as the first one is sometimes saying something is normal is the kind of hardest thing to do at the end of the day. But this is a basically normal EKG. A rate of 45 is a bit low, so you'd want to know the clinical context. I will tell you because I know that for this patient. This is a healthy 50-year-old marathon runner. That 45 is not an abnormal rhythm. They're asymptomatic. It'll officially be a sinus bradycardia, but this is a normal EKG. What are some things we wanna know? We wanna be able to pick up rates and the computer's really good at predicting rates, but still, every once in a while, especially with, you know, telemetry monitors, they'll be double counting or wrong counting and so just knowing that in general when we're looking at rates, what we're looking at is we're looking at, uh, OK. The simple pattern of taking 1500 and divided by the small number of small boxes or 300 by the number of large boxes. So I think it's within our priview for all of us to know that if the QRS complexes are separated by one box, that's a rate of 300. 2 boxes, 150, 300, 150, 75, and on it goes down by halves. The computer's pretty accurate, but we should always in our mind just double check that. Um, this is an interesting EKG. And it's probably the most common EKG abnormality we see as we're reading large EKGs off the queue. This is again a sinus rhythm. The rate looks pretty good. It's more than 2 boxes. It's probably somewhere around 80 or so. But what's abnormal on this EKG is the leads are, are not correctly positioned. Whoever's positioned these leads has accidentally reversed the limb leads, and so lead one should be an upward one to have a normal access. It's down and AVR is up. This is a lead inversion that's gonna be the most common abnormality or a missing lead. Sometimes you'll see one lead that just has a blank space. If it's important information we're missing, we often have to repeat those studies, but that's one of the things to be on the lookout for. Access is the next thing we kind of wanna think about whenever we're looking at EKG leads, we're basically looking at the direction of current flow at the surface of the body. And so that far left one, that's a predominantly positive QRS complex. The next one is predominantly negative. It's not a matter of which direction it's moving, it's the bulk of the shaded area. Where is it relative to the baseline? And third one is aquiphasic. And the reason that's important is when we look at the axis of conduction, for example, if the heart is in the correct position in the chest, the electricity should generally be moving in a downward, leftward motion. And so again, I'm not belabor the point, but a normal axis tends to be along that interval. And so the simple way to think of that is, as you're looking at the rate and the rhythm, let your eye drift at leads one and lead AVF, and they should basically both be up. If they're double thumbs up, you've got an axis that's downward and towards the left, that's a kind of normal axis. We could talk for hours about some of this stuff, but I'm trying to move at a little bit of a brisker pace. All right, EKG number 2 should be easy for anyone that listened to our last series of talks. I'm not gonna belabor the point because you've seen these EKGs. This is Afib, right? There's some conduction abnormalities. The QRS interval is just a little bit longer than you'd expect here. There's an irregularly irregular rhythm. What else causes an irregular irregular rhythm when it's not Afib? Doctor Patel is not allowed to answer that question. He was trying to, trying to uh phone a friend. Speak up, I think I heard some, some muttered answers. Say that again. Yeah, so you can have it as a result of a normal respiratory variation. You can have a regularly irregular pattern with, for example, PACs or PVCs, but the other thing we think about is multifocal atrial tachycardia, MAT. There are P waves, but they're very different. They're coming from different places, and so that's one thing to think about along the way. This is our rate rhythm thing, right? The rate, if it's one box away, it's 300, 150, 100, 75, 60, 50, and on it goes down. The computer's pretty accurate about that, but I would urge you just get in the habit of just double checking and make sure you agree with it. I'm not gonna talk about Afib or a flutter because we've heard enough about that. All right, this is starting to get fun now. Number 3, you get 15 seconds. Each of you should be writing down what you think. You would answer for this EKG. It's clearly not normal. So that one's easy. 10 more seconds and we're gonna go through. This one is a fun enough one. I'm gonna ask someone to raise their hand and volunteer to share their answer. I'm gonna answer. I'll call out the first hand I see that's not an EP. All right, I see a hand up. So her question is, is this ventricular tachycardia? Now, when I was in training as a fellow and we're about to start a fellowship program, I love that you've jumped to that cause, cause that actually is the correct answer. But what you want to do is you want to get like as many quick points as you can. So when we were fellows, what we learned to say when we look at EKG like this is we say, oh, this is a study from July of 2008. Absolutely correct. I got like a half point because it was obvious, right? Second thing you're gonna say is, is. It looks fast. This is a fast. This is a tachycardic rhythm. And it appears to be a wide complex. So even if I get the rest wrong, I've gotten 3 points, the date, that it's fast, and that this is wide complex, right? Now the question becomes, how do I actually get to where you are? This could be VT. What else could this be that's fast and wide complex. Could be an SVT or an AFib or something like that. Now it's pretty regular, so it's gonna be hard for me to convince uh Doctor Patel to ablate this person for AFib because he's just not gonna buy that. But how do I know this is coming from a ventricular position and not a position higher than that? And I'm not gonna make you go through this, but if we really look carefully and compare one beat to the next, this is a ventricular tachycardia, and there is also a sinus rhythm underlying it at a slower rate. And because that rate is slower. And you have a sort of disconjunction of those two. The atriums trying to do its thing and the ventricles trying to do its thing. We have dissociation of the atrium and the ventricle. For a cardiologist, those are the three lines you have to have in there to get your full credit on the boards. For you guys, you did a great job answering that. This is a ventricular tachycardia. We need to know more about the patient status. If they're unstable, we're very quickly treating this with cardioversions and other things like that. We still are thinking about treating this pretty aggressively, even if they're not symptomatic, but good job. So VT here, REPs, anything to add that I didn't say on that that's important? capture Oh, I love it. Yeah, in the middle, yeah a fusion. So, so let me, let me say that louder. There's also what's called a captured beat. Occasionally if you get things lined up just right, you might get a beat coming from the, the upper chambers conducting down. So that's a great point as well. And I think I wanted to add is before we like delve deep and like the rhythm, first thing that's also important is to ask about the age of the patient and then. Just because if the patient is like in the 70 years old, then you're, you know, you're thinking more VT side like more if the patient tells you that he has a history of a stent or a heart attack, then you're already kind of veering towards 75% of white complex attack at that age is already VT versus you see someone who's like 21 years old, then you're more thinking about unless with the overt, you know, history, then you're thinking more about a WPWish, you know. And that is important when you're calling with that EKG when you're texting uh Div at 11 p.m., which anyone that gets to ask and answer gets a free extra call to uh Doctor Guerina and Doctor Patel late at night. But um, you want that history is important, known history of heart disease, low EF, that's gonna shift your brain already, so statistically you're playing the odds. These are great points. All right, number 4. All right, 15 seconds and I'm looking for a hand up to tell me what's going on. And even you're not putting your hand up, I want you to write down what you see so that, you know, you're predicting and, and calling it. Say it, say it louder. So this is what looks like a pace rhythm. Now, let's go a step further. Can you tell me anything about the kind of pacing this patient's getting? So there's a, there's two spikes before the, the QRSs, right? There's a space, a a spike before the P wave and a spike before the QRS. Um, this is a dual chamber pacemaker. Now, when, when I gave this talk last, and for this audience, I think we can tell a lot more about. We can tell about where the pacing is occurring in this era and it's beyond the scope of today's discussion. We can put pacemaker leads in different places, multiple leads to the ventricle. Leads in specific areas that use electrical conduction system. I'm gonna, I'm gonna forego all that just because in the interest of the time that's an hour long talk, but I promise if you come in October, someone's gonna talk about that stuff and you get to hear next level there. But I think it is important now again, here's where history and other information helps you. But when you see those pacing spikes, just double check if you didn't realize that patient had a pacemaker that they have one. And the reason that's important, you might say, well, that's the cardiologist's job, and it absolutely is. However, In this era with us spread over such a large geographic distribution, probably at least once a week someone comes into our hospital system with a pacemaker at end of life who somehow didn't really get structured where they're following up in the pacemaker clinics and so as a primary care provider, as anyone taking care of the patient, if you can sort of have that in your head as to whether there is pacing going on that if they're not seeing one of us, they need to be seen by us and be monitored. All right, EKG number 5, we're gonna pick up the pace a little here. Number 5, you guys get 15 seconds, and I'm looking for a hand up to tell me what's going on with this rhythm. Oh, wait, to someone that hasn't answered before. OK, where, where did that come from? I was, uh, you already answered someone else. You get, you get two lunches otherwise. Someone else that wants to eat some lunch. All right, what is it, what's going on with this rhythm? OK, so, I love it. You guys are good. You jump to the important stuff. Remember, to get your full board's credit, what you already know is there is, there is a sinus rhythm, right? There are also QRSs. But if you really march those things out, there's no link on that 1234, 5th, 6th beat. It kind of looks like that P wave might be causing that QRS. So you think to yourself, hmm, is there some intact conduction or not? But as you trace them out, if you. Take your calipers or just take a piece of paper, overlay it and make marks at every P wave and marks at every QRS, you'll see that there are really two separate rhythms here. All right, so this is a 3rd degree AV block, complete heart block. Um, and there are multiple levels that blocks can occur. A 1st degree block is simply when you have a long. P wave to QRS along PR interval, right? Um, beyond first degree blocks you can have two types of second degree blocks. The classic Wenky block tends to be a tends to be a more benign block. You have prolongation of the PR intervals. Again, I'm gonna not belabor this point with the 2nd degree, um, Mobis type 2 blocks, there tend to be fixed intervals and just drop beats. That can obviously be hard to tell sometimes if they're missing every other beat what that is. And to the points we've heard earlier, you look at the history. History you look at what's their EF, you look at the width of the QRS. There are other important factors that weigh into this. These patients that have higher level blocks and are symptomatic are ones we kind of need to be seeing. Um, give us a call about those patients. Many show up in the EDs and end up with concerns about whether they might need a pacemaker or not. Again, longer topic than we have time for today, but this was a 3rd degree block. Nice job picking that up. At least 3 people are getting lunch. The rest of you, the pressure's on in these last 5. OK. All right, let's go to number 6. Number 6, EKG. Oh, EKGs every primary care provider should note. 15 seconds for you to write down stuff and then I'm looking for a volunteer. OK, let's hear it. Good. So again, sinus rhythm cusses look wide, but this is WPW. This patient has an accessory conduction pathway. Now the EPs in the audience and hopefully all the cardiologists are starting to figure out from this EKG where even that exists. But for a, from a primary care audience, you don't have to figure out where that pathway might exist. You have to know that there's aberrant conduction where part of the electrical signal from the upper chamber is not delaying before it goes to the lower chamber. This can be a danger. rhythm we see this in young people. WPW is becoming an extinct entity in our region because our EPs are so quick to manage to ablate it out, but it's important to recognize, and the idea is you have this accessory pathway that can allow aberrant conduction one direction or the other and participate in dangerous circuits. When these patients go into Afib, they can have really dangerous fast heart rates. So good job on that one. All right, number 7. 15 seconds to look and then I'm looking for a volunteer to tell me what's going on. Oh, thank you. Yes, let's hear it. Excellent, so, so who here was going to say that also? Oh, sorry, what she said is sinus rhythm. She wanted the full cardiology credit for this, right? The QRS complexes appear to be wide, and she jumped to appropriately saying this is a left bundle branch block. When I give this talk and have given this over the last 20 years, it's interesting. I think this is one of the ones determining a right bundle branch block versus a left bundle branch block is something that's a little bit more challenging without a little bit of exposure to an experience. It tends to be something that's harder for people. So just as, as a, as a thought of curiosity, who in here also was thinking this, this looks like a left bundle branch block to me. Couple hands up. Was anyone thinking, hey, this is a bona branch block. I don't know if it's left or right, yeah, a couple hands there as well. This one I'm gonna spend a minute on and just tell you this is important clinically at multiple levels, not just from an EP perspective, because when you have bundle branch blocks, they can have implications for heart function, for types of pacemakers we think about, but as an interventional cardiologist, this is important when you're ordering stress tests. A right bundle branch block, which this is not, does not inhibit us from reading EKG level stress testing. A left bundle branch. Block does. Also, a left bundle branch block can mask a lot of the EKG findings that predict ischemia. So a new left bundle branch block to an interventional cardiologist is the same as ST segment changes that make us think about rushing to the cath lab. So it is pretty important for us to all know the difference between a left and a right bundle branch block. I would love 15 minutes to go through this. I have 2 minutes, so I'm gonna tell you the simple way I think of this, right? The, the what you want to think about with bundle branch blocks blocks is a very simplified but clinically reasonably accurate explanation of what's going on is if you simplify the heart as having a right bundle that goes to the right front side of the heart and a left bundle that goes to the left back side of the heart, reality is more complicated, but if we simplify it to that, if one of the bundles is blocked, then you're not gonna have early conduction in that direction. You will only have late conduction in that direction. So I want you to learn to take the QRS. Identify your QRS and cut it in half and to identify bundle branch blocks, if the QRS duration is prolonged, and, and I love that I see people taking their phones out and taking photos, you're also welcome to complete copies of my slides. a million people have these slides already from past years, but anyone that wants it, email me at tareja@yahoo.com and you can have this whole set. But I've drawn a gray line to cut the middle. Ignore the first half, because that's when your working bundle is kind of doing its thing. You're gonna look at the second half, all right? And typically look at two leads. In this case, I picked V1 and V6. Um, you can often use uh lead V1 and lead one as well. But what you're looking at is what direction is the second half of the conduction. In this case, in V1, the second half of conduction in V1 is greened out there. It's above the baseline. It's moving towards lead. V1 late conduction is moving anteriorly, all right? In V6 late conduction, the green area is below the baseline. It's moving away. So it's not moving towards the left. Lake conduction is moving anteriorly and towards the right. And that's what tells me when I have a right bundle branch block. Many of us learn things like look for rabbit ears and stuff like that. It's OK, but that isn't entirely accurate all the time because there can be sort of complexities. Um, uh, again, I don't have the time I'd love to normally dedicate to explaining this, but when lead V1 and lead 1 or lead V6 instead of 1, either of those, when the late forces move opposite from each other, that's going to be either a left or right bundle. When they're in the same direction, it doesn't really fit with either of those. We'll typically call that a non-specific intraventricular conduction delay. This is a lot to take in, but at the end of the day, if I were to have you remember something, in lead 1 and lead V6 here. All right. Uh, you see that, uh, in this case, we've got. Conduction, look at lead one, for instance. If I cut that in half, the late conduction is upward in V1, and let's look at V1 maybe there. In V1, you see the late conduction is headed down. This is a left bundle branch block, just like you identified very astutely in this patient. This is now what's gonna be a right bundle branch block. You look at lead one, and the late forces are headed away from one and they're headed towards V1. Lead one and lead V1, that last table I showed you is what's gonna break it down. This topic deserves another 15 minutes for you to understand, but I'm gonna share the slides with anyone that wants them. And if you go through this a couple of times and learn to use two leads, and maybe let's just say one and. V1 are probably the easiest. If you can't see one well, you can use V6 as well, but looking for differential late conduction and deciding which direction it's headed will help you pick this up more accurately than the rabbit ears. The point of my including this is I think left and right bundles is something it's worth us taking the time to focus on offline when we have more time. I'm happy to take this in more detail with anyone who wants to see it, but for ischemic workups. That's important to be able to tell that difference. And this puts them side by side and shows those examples. Again, not enough time to really make this clear for someone that hasn't had some exposure before, but I'm happy to share the slides and, and that's the, the pivotal part of it. This is now a right bundle branch block. If this patient had an EKG stress test, I could make something of it. If this patient came into the ED with chest pain, I'm not freaking out on the front end and calling in the STEMI team. All right, 3 to go, and these are quicker ones. Number 8. 15 seconds and I'm looking for a hand. If I don't see a hand up in 10 seconds, I'm volunteering George in the back there. Oh, was there a hand where? All right, we'll let you go again. You get 2 lunches or 2 desserts. OK. OK, so sinus rhythm, good connection. And a little tachycardic, all right. Sinus tachycardia, what else is there anything else that would catch your eye on this EKG? That's good enough I hear soft things, but my ears aren't good enough to make them out yet. What I'm looking for on this is the other thing that really sticks out on this is those are pretty tall looking QRS complexes. There are important criteria that again are listed here. This patient has LVH. We need to think about what else do we do. We can pick up LVH, RVH, left atrial and right atrial abnormalities on EKGs, and because in a hypertensive patient with this kind of an EKG, I'm gonna worry a little bit. About what's their wall thickness? Could this be something like hypertrophic cardiomyopathy? Could it be at that level? LVH is another important thing to look at. There are a lot of criteria. The standard one are called the SDS criteria. I would say from a primary care perspective, just noticing when you have significant voltage on the left ventricle is something that's important to pick up on EKGs because again, that's a patient we're gonna want to be more aggressive about treating their hypertension. Hypertension is an exciting area for all of medicine. It's really primary care doctors do an incredible job taking care of it. We're about to start our first renal denervation procedures. Doctor Ron McKechnie will do a couple of those, and that's gonna be featured in some of our Centera stuff. The, the, uh, the spectrum of what we have to treat hypertensive patients, newer medications coming out, older medications available, and now even, even percutaneous therapies for treating it is ever growing, and you'll hear more about that in the next conference, but that was my appointment number 8. All right, let's go to number 9. You got 2 more chances to earn lunch here. Number 9, let's see a hand up once you guys have had a chance to take a quick look. Yes. All right, I like it. Again, you've jumped, you guys are, are aggressive, you get right to the end. So, this is a sinus rhythm at a rate of something like uh 90 beats per minute, 53 year old patient. And there are clearly ST changes here, right? The ST segments are abnormal. And if you look at leads 23, and AVF, what we're really worried about in this patient is those ST segments are elevated. This is an emergent move to the cath lab. This is if the patient's not in the ED, they need to be in the ED as quickly as possible. Time is muscle, and our cath lab teams are activating the minute anyone sees this EKG. And you're exactly right. When we think about where the abnormalities is, this is an inferior. ST elevation pattern. If you look at the screen for a second, I've laid out leads V1 and V2 are anteroseptal, V3, V4 are anterior, V5, V6 are lateral, and they can bleed into leads one and AVL and leads 23, and AVF, which are the abnormal ones here. That's inferior ST segment elevator. This is an inferior STEMI. These patients get very sick very quickly, especially if they have RV involvement. We can do right-sided leads as well to look for that. This patient needs to be in the cath lab as quickly as possible. And if there's not a cath lab available, they need to be getting lytics and then on a helicopter to somewhere that has a cath lab available. We can have anterior ST elevation we see in some of these. Now we can also have other things that look like that. Some patients have early repolarization. Some patients are paced. That's where we're looking for pacemaker leads is important. Some people have a left bundle which will count as this as well. You guys are doing great. So last one here is EKG number 10. This is your last chance to get a, uh, opportunity to, to share what you see. Looking for a hand on this one. Doctor Yusupov is doing a great job helping me see them. Uh, we might not be going to lunch. All right. Say, say that a little louder. OK, good question. So this looks a lot like what I showed you before, right? We've got a sinus rhythm, a rate of, uh, something like 90-ish, 85, 90 beats per minute. We've got ST elevation. Now, the next step when I see ST elevation is decide what is this likely to be? What leads are involved? Is this an infarct or is this something else that looks like that? So, so for, for, for extra credit in the audience, where, which leads do we see ST segment elevation in? All right, someone's calling out anterior. What about 23F? Do we have any there? Inferior and anterior and lateral, there's a lot of ST elevation in this patient. This is, this might be a really bad MI. What if I told you, now this is a 71 year old, what if I tell you this guy's having more pleuritic type chest pain? Oh, pericarditis becomes an interesting suggestion as well. What else will tell us if this is maybe pericarditis on an EKG? ST elevation for sure and it you can argue it's a smiley face concave up ST elevation. What else? Say it again. Uh, arrhythmias can be associated with SVT and so forth. What I'm looking for a little bit is PR segment depression. If you take a piece of paper and lay it even with the TP segments, you'll notice that, look at lead three there. After the P wave, that, that segment from the P wave to the QRS is depressed, it's downward. Hearing the history of pleuritic pain, maybe a recent viral infection, and seeing diffuse ST elevation with TR depression. I will put my money on this likely being pericarditis and actually of course I know the case, so it was pericarditis, but could it be a STEMI? Yes, we still have to think about that. This could be pericarditis post an an immediate MI and so we're gonna need to pay some attention, probably gonna get some enzymes and look at stuff, but this is pericarditis and it's just a little bit different from EKG 9. Pull them both up and flip back and forth. And if I had to, uh. Say the differences the PR depression here and the clinical history is what's gonna push us to pericarditis. Last thing I'll tell you is for those that love this stuff, there is a great EKG site. It's EKG Pia. Uh, they have a lot of great talks, a lot of great EKGs. You can pull EKGs off of it. I'm happy to share my slides and would love to talk offline about any of this that we didn't get time for. I'm gonna turn the flat, the flat, the floor over back to the boss again though. Thanks for inviting me. Published Created by Related Presenters Deepak Talreja, M.D. Sentara Cardiology Specialists View full profile
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