interesting ecg- dept .cardiology,mgm medical college,indore

1. ECG OF THE MONTH
CANDIDATE : DR.SARATH MENON.R
DEPT. OF CARDIOLOGY
M G M MEDICAL COLLEGE,INDORE

2.  55 yr old male, labourer,c/c smoker from Jabua
admitted in ICCU on 8.01.2011 with c/o of
palpitation, gabrahaat for duration of 4-6 hrs.
no h/o chest pain,dyspnoea,syncope
 o/e-
conscious,oriented
no pallor,cyanosis,clubbing,edema
JVP raised.
pulse- rapid ~ 170/mt regular
BP- systole 80/60

3.  S1- variable. S2- normal
 Chest – b/l clear ,no added sounds
 P/A- soft,non-tender
liver,spleen –non palpable
 Past history
- h/o similar episodes before
- h/o MI – 5 yr back

4. ECG AT TIME OF ADMISSION (BEFORE DC)

5. ECG AT TIME OF ADMISSION

6. ECG -AFTER DC CARDIOVERSION (200J)

8. DIFFERENTIAL DIAGNOSIS
 Ventricular tachycardia
 Supra ventricular tachycardia with abberancy

9. DISCUSSION –WIDE COMPLEX TACHYCARDIAS
 Definition
 Ecg features
 Diagnostic criteria
- Brugada criteria
- Lead aVR algorithm

10. DEFINITION
Wide QRS complex tachycardia is a rhythm with a rate of more than
100 b/m and QRS duration of more than 120 ms
SVT (20%)
VT (80%)
Stewart RB. Ann Intern Med 1986

11.  VT- 3 or more consecutive ventricular premature
beats with a rate of 100/mt or more
 SVT- a tachycardia dependent on participation
of structure at or above bundle of His
 LBBB morphology- QRS > 12 msec. with prominent
negative deflection in V1
 RBBB morphology- QRS > 12 msec. with prominent
positive deflection in V1.

12. DIFFERENTIAL DIAGNOSIS
 Ventricular tachycardia ( 80 %)
 SVT with abberant conduction (20%)
- SVT with BBB abberancy (fixed or functional)
- pre-excited SVT (anomalous AV connection)

13. SVT VS VT
CLINICAL HISTORY
Age - ≥ 35 ys → VT
Underlying heart disease Previous MI → 98% VT
Pacemakers Increased risk of ventricular tachyarrhythmia

14. PHYSICAL EXAMINATION
 Signs of AV dissociation favours VT
- cannon waves
- varying intensity of S1
- variation of systolic BP
- hypotension
 Termination of WCT with maneuvers ~
carotid,vasalva,adenosine favours SVT

15. ECG
 Rate
 Regularity

16. BRUGADA CRITERIA

17. STEP 1- RS COMPLEX IN PRECORDIAL LEADS

18. STEP 2- R TO NADIR OF S (BRUGADA SIGN)

19. STEP 3- A-V DISSOCIATION

20. STEP.4- QRS MORPHOLOGY

21. VT WITH LBBB MORPHOLOGY

22. SVT WITH LBBB MORPHOLOGY

23. STEP 4- VT WITH RBBB MORPHOLOGY

25. SVT WITH RBBB MORPHOLOGY

26. OTHER ECG FINDINGS FAVOUR VT
 North - west QRS axis deviation
 Negative or positive concordance
 Fusion beats, capture beats
 Ventriculoatrial conduction with block
 Axis shift of > 40° from SR
 RBBB morphology with LAD > - 30°
 LBBB morphology with RAD > + 90 °
 In LBBB, QRS duration >160 ms
 In RBBB,QRS duration > 140 ms
 Previous ECG show MI or previous ECG show that during
sinus rhythm, bundle branch block is present, which changes
in configuration during tachycardia

27. RABBIT EAR

28. CONCORDANCE & NORTH WEST AXIS

29. POSITIVE CONCORDANCE

30. FUSION & CAPTURE BEATS

31. VT VERSUS AVRT

32. LEAD AVR

33. AVR ALGORITHM

34. OUR ECG
Favours VT •Against VT
 h/o MI  Axis is normal
 v4 RS complex  Not typical vt LBB
duration RS >100 ms morphology
 A-v dissociation  Qrs duration .14 s with
 Avr s/o vt lbbb
 Initial axis shift > 40°  Non concordance
 Presence of RS complex

35. CONCLUSION-DIAGNOSIS
 VENTRICULAR TACHYCARDIA WITH LBBB
MORPHOLOGY
 CAD- OLD ANT.SEPTAL MI
 QT PROLONGED

36. SUMMARY

38. THANK U….