The document summarizes several interesting ECG cases presented by Dr. Pradeep Katwal. It includes cases showing sinus exit block type II, anteroseptal myocardial infarction, SVT with aberrant conduction, WPW syndrome, inferior MI with right ventricular extension, Brugada syndrome, acute pericarditis, Takasubo cardiomyopathy, and hypothermia presenting initially with complete heart block and later with SVT. The document provides details of the patients' histories, initial ECG readings, diagnoses, and key features of each condition identified on ECG.

1. INTERESTING ECGS
Moderator- Dr. Thomas John
Presenter-Dr. Pradeep katwal

2. ECG included
• SINUS EXIT BLOCK type II
• Anteroseptal wall myocardial infraction
• SVT with aberrant conduction
• WPW syndrome
• Inferior wall MI with right ventricular extension
• Burgada syndrome
• Acute pericarditis
• Takasubo cardiomyopathy
• Hypothermia
• CAD with single vessel disease presenting initially with
complete heart block and later with SVT.

4. What is ECG?
• ECG is graphical recording of electrical activity
of heart from body surface using multiple
electrode placed over the body.

5. The Normal Conduction System

6. All Limb Leads

7. Precordial Leads

8. Interpretation
• Systematic approach to reading EKGs :
• Rate
• Rhythm (including intervals and blocks)
• Axis
• Hypertrophy
• Ischemia

9. Waveforms
The electrical pattern of the cardiac cycle shows waves and
intervals.

10. Electrical axis deviation of heart

11. Case 1
• 68 ys old male presented in emergency with
history of progressive shortness of breath and
generalized swelling of body.
• Vitals
– Pulse-32/min
– B.P.-90/60 mm hg

13. INTITIAL ECG

14. • SINUS EXIT BLOCK type II
• PP intervals fairly constant (unless sinus
arrhythmia present) until conduction failure
occurs
• The pause is approximately twice the basic
PP interval

15. • 2ND DEGREE AV BLOCK

16. • S.creat: 4.5 mg%
• S. potassium: 7.1 mEq/l
• Urea : 164 mg/dl
• DIGNOSIS- CHRONIC KIDNEY DISEASE SATGE 5-
METABOLIC
ACIDODIS, HYPERKALEMIA, ANEMIA OF
CHRONIC DISEASE

18. CASE 2
• 76 Yrs old male, emergency
• C/O
– Epigastric pain * 2 days
– Vomiting *2 episodes
• Vitals
– Pulse-72/min
– B.P.-100/68 mmhg

19. Initial ECG

20. At 12 p.m.
• Call was given for sudden onset shortness of
breath.
– pulse rate- 280/min
• ECG showed-

21. ecg2

22. VT versus SVT with aberrancy
• Very broad complexes (>160ms)
• A V dissociation
• Capture beats
• Fusion beats Positive or negative concordance
throughout the chest leads, i.e. leads
• V1-6 show entirely positive (R) or entirely negative (QS)
complexes, with no RS complexes seen.
• Brugada’s sign – The distance from the onset of the QRS
complex to the nadir of the S-wave is > 100ms
• Josephson’s sign – Notching near the nadir of the S-wave
• RSR’ complexes with a taller left rabbit ear .

25. • Angiography-coronary artery disease, single
vessel disease-Right coronary artery occlusion
• Stenting was done with BMS

26. ECG3

27. Case 3
16 yrs old male without significant past medical history
presented with H/O palpitation on and off.
Vitals
• Pulse-76/min

28. ECG2

30. ECG criteria include all of the following
Short PR interval (<0.12s)
Initial slurring of QRS complex (delta wave)
representing early ventricular activation
through normal ventricular muscle in region of
the accessory pathway
 Prolonged QRS duration (usually >0.10s)
 Secondary ST-T changes due to the altered
ventricular activation sequence

32. ECG1

33. AVRT With Orthodromic Conduction
• Rate usually 200 – 300 bpm.
• Wide QRS complexes due to abnormal
ventricular depolarisation via accessory
pathway.

34. CASE 4
• 68 yrs old male
–Chest pain since 4 HOURS
–a/w Shortness of breath, vomiting
Vitals
–Pulse-86 JVP-raised
–B.P.-100/60 mmhg

35. ECG 1

36. observe
• ST elevation in V1
• ST elevation in lead III > lead I

37. ECG 2
• RIGHT SIDE ECG

38. • Right ventricular infarction is confirmed by
the presence of ST elevation in the
right-sided leads (V3R- V6R).
The most useful lead is V4R, which is obtained
by placing the V4 electrode in the 5th right
intercostal space in the midclavicular line.

40. Right venticular infraction on EKG
ST elevation of 1 mm or more in lead V1 and
lead V4R.
Failure of development of reciprocal changes
in right precodial leads.
Decrease in magnitude of ST elevation in leads
V1-V5
Discordant relationship of ST changes(ST
elevation in lead V1 and depression in lead
V2)

41. CASE 5
• 34 YRS OLD HYPERTENSIVE MALE
– ASYMPTOMATIC
– DURING ROUTINE CHEAK UP

42. Diagnosis

43. Burgada syndrome
St-segment elevation in V1–V3 in sinus rhythm
Elevated ST segment (≥2 mm) descends with
an upward convexity to an inverted T wave
Provoked with the sodium channel-blocking
drugs
Risk of polymorphic ventricular arrhythmias

44. CASE 6
• 19 ys/F, with 5 days history of central chest pain and
fever. Her pulse rate was 74 beats/min and her
ECG showed-

46. EKG Manifestations of Acute
pericarditis
Sinus tachycardia
Taller, Peaked and symmetrical T waves
Elevated Concave upwards S-T segment
without reciprocal changes
The PR segment elevation on lead AVR.

47. • Stage I
everything is UP (i.e., ST elevation in almost all leads - see below)
• Stage II
Transition ( i.e., "pseudonormalization").
• Stage III
Everything is DOWN (inverted T waves).
• Stage IV
Normalization

48. Case -7
• 63 year old lady is brought Emergency with
central crushing chest pain.
• She has no previous medical history and was
in the mortuary to see the body of her son
who’d just died from a subarachnoid
haemorrhage..

49. ECG

50. She’s taken to angiography where she’s found t
o have normal coronary arteries.

51. Mayo Clinic criteria for tako-tsubo
cardiomyopathy
1. New ECG changes (St elevation or T wave
inversion) or moderate troponin rise.
2. Transient akinesis / dyskinesis of left ventricle
(apical and mid-ventricular segments) with
regional wall abnormalities extending beyond a
single vascular territory.
3. Absence of coronary artery stenosis >50% or
culprit lesion.

52. Left ventriculogram

53. CASE 8
• 45 yrs old male, following exposure during a
cold winter night as a result of alchohol
intoxication was brought to ER.

54. ECG

55. • Sinus Bradycardia
• Low amplitude P waves
• Increased venticular activation time
• HUMP LIKE DEFECTION of the distal limb of
QRS complex with S-T segment: OSBORN W
AVES
• Prolonged Q-Tc interval

58. Thank you