1. Case-oriented EKG’s
(level 1- easiest)
MDFPR
July 1, 2009
M. LaCombe

2. The normal EKG waveform

3. A normal EKG

4. The frontal plane (QRS) axis:

5. Case#1: The patient is a 47-yr-old female who is
asymptomatic with the following ECG finding
reportedly since birth.

6. The tracing shows sinus rhythm with complete
heart block and an A-V junctional type escape
rhythm. The P-P interval surrounding an
individual QRS complex is narrower (shorter)
than the P-P interval between two QRS
complexes. Sinus rate variation with complete
heart block is called ventriculophasic sinus
arrhythmia. The patient has congenital
complete heart block. This entity is usually
idiopathic but may be secondary to placental
transfer of anti-Ro and La antibodies from the
mother. The spectrum of disease ranges from
patients who are born with severe bradycardia
and require pacemakers in infancy to patients
who live full life spans without artificial
pacemakers. The overall infant mortality is
15%. The escape rhythm in this instance is
proximal in the conduction system and a
pacemaker is not required at this time.

7. Case #2:
34-year-old male. What's going on here?

8. ECG shows classic findings of
acute/hyperacute anterior wall Q wave
myocardial infarction (MI), with reciprocal
inferior ST depressions. The distribution of
changes is consistent with a proximal left
anterior descending (LAD) occlusion which was
confirmed at cardiac catheterization and
treated with angioplasty/stent. Premature
atherosclerosis here was associated with
multiple risk factors for coronary artery
disease:hypertension, hyperlipidemia, family
history and tobacco.

9. Case #3:
47-yr-old male. What is the diagnosis? What
should you do?

10. Acute anterior wall myocardial infarction (MI)
ST-elevation (STEMI), consistent with proximal
left anterior descending (LAD) occlusion, with
Q waves (V1-V3) and ST elevations (V1-V5).
Page interventional cardiology, stat!
Emergency Treatment: aspirin, beta-blocker,
nitroglycerin, morphine, etc, unless specific
contraindications exist, with plans for
immediate reperfusion therapy.
See: J Am Coll Cardiol 2004;44:671-719.

11. Case #4:
64-year-old male with chest pain. What vessel
was acutely occluded at catheterization?

12. The left anterior descending (LAD). The patient
actually had multivessel disease. The ECG
shows an extensive acute/evolving antero-
lateral myocardial infarction (MI) pattern. The
rhythm is borderline sinus tachycardia with a
single premature atrial complex (PAC)-(4th
beat). Note also low limb lead voltage and
probable left atrial abnormality (LAA). Left
ventriculography showed diffuse hypokinesis
as well as akinesis of the antero-lateral and
apical walls, with an ejection fraction of 33%.

13. Left anterior oblique caudal angiographic
projection demonstrating total occlusion of the
proximal left anterior descending artery (open
arrow). Also noted is ramus intermedius
disease (closed arrow) as well as circumflex
system disease (small arrows).

14. Transthoracic apical four-chamber
echocardiographic image demonstrating
antero-septal and apical aneurysmal dilation
(arrows) of the left ventricle (LV) post-LAD
infarct. LA = left atrium; RV = right ventricle;
RA = right atrium.

15. Dual isotope stress (top rows) and rest (bottom rows)
images demonstrating fixed distal anteroseptal (straight
white arrows) and infero-basal (angled arrows) perfusion
defects. Note both defects are seen in multiple views.
Short axis (SA) images are arranged from apex to base;
vertical long axis (VLA) images are arranged from
septum to lateral wall; and horizontal long axis (HLA)
images are arranged from inferior to anterior.

16. Case #5:
26-year-old man prior to enrolling in anti-
convulsive medication trial. Are there any
abnormalities?

17. No. Within normal limits. Precordial
voltage is prominent but within normal
range, especially in young adults,
without left atrial abnormality or ST-T
changes of left ventricular hypertrophy.

18. Case #6:
Why is this young cocaine abuser in the emergency
department?

19. He is having an evolving anteroseptal
myocardial infarction secondary to
cocaine. There are Q waves in V2-V3
with ST segment elevation in V2-V5
associated with T-wave inversion. Also
noted are biphasic T-waves in the inferior
leads. These multiple abnormalities
suggest occlusion of a large left anterior
descending (LAD) artery that wraps
around the apex of the heart (or
multivessel coronary artery disease).

20. Left anterior oblique caudal angiographic
projection demonstrating total occlusion of the
mid-LAD (open arrow) distal to the takeoff of a
large first diagonal branch. Also noted is a
90% tubular stenosis of the first obtuse
marginal branch (closed arrow).

21. Rest thallium images showing antero-apical perfusion
defect (arrows), which appears as an area of decreased
tracer counts. Vertical long axis (VLA) slices are
arranged from septum to lateral wall. Horizontal long
axis (HLA) images are arranged from inferior wall to
anterior wall. Short axis (SA) images are arranged from
apex to base. Image shows apex centrally, out to base
on the periphery

22. Case #7:
What is the EKG diagnosis in this 48- y.o. man?
• Early repolarization (normal variant)
• Acute pericarditis
• Acute anterior wall STEMI
• Hyperkalemia
• Systemic hypothermia with Osborn waves

23. •Early repolarization (normal variant)
•Acute pericarditis
•Acute anterior wall STEMI
•Hyperkalemia
•Systemic hypothermia with Osborn waves

24. c) Acute anterior wall ST elevation MI
(STEMI) Note the marked ST elevations
and hyperacute T waves in the
anterior/lateral leads, including V2-V5, I
and aVL. Slight reciprocal ST
sagging/depression is present in lead
III. There is decreased R wave
progression in lead V2, consistent with
an acute myocardia infarction (MI) as
well. The patient had sustained an
occlusion of the proximal left anterior
descending coronary artery.

25. Aside: Osborn Waves or J waves seen in hypothermia

26. Segue:
Famous People Who Died
Young, from Coronary Disease

27. Jim F Fixx 1932 - 1984, 52-year-old Jim Fixx collapsed while out jogging July 20, 1984
and died of a massive heart attack. Autopsy revealed extensive heart disease with
coronary artery blockages of 99%, 80%, and 70%. Jim took up running in the 1960's
when he weighed 220 lbs. He is credited with helping start America's fitness revolution,
popularizing the sport of running. His best-selling book, 'The Complete Book of Running'
was published in 1977 and sold over 1 million copies. By that time he was jogging an
average of 60 miles every week and his weight was down to 159lbs. In 1980 he published
Jim Fixx's 'Second Book of Running: The Companion Volume to The Complete Book of
Running'. Jim's father died of a heart attack at age 43 and Jim's cholesterol levels was
above 250 mg/dl. He was survived by four children.

28. Darryl Kile 1968 - 2002, the St Louis Cardinal pitcher complained to his brother Daniel of
shoulder pain and weakness Friday June 22, 2002, the night before he died, possible warning
signs that he had heart problems. Kile was found dead Saturday in his 11th-floor hotel room at
the Westin Hotel after he failed to show up for St. Louis' game against the Cubs. The night
before, he had gone to dinner with his brother, Daniel. Daniel reported that Darryl said his
shoulder was hurting and that he felt weak but "For a guy who was a pitcher in the major
leagues, (the weakness) was an unusual symptom" . Kile's father died from a heart attack in his
mid-40s.An autopsy on Kile, 33, revealed an 80 to 90 percent narrowing of two of his three
coronary arteries, said Dr. Edmund Donoghue, the Cook County medical examiner. Cardinals
spokesman Brad Hainje said Kile had a physical examination during spring training. He said he
was not aware of Kile complaining of chest pains.

29. Brian Maxwell 1953 - 2004, collapsed Friday March 19, 2004 at a post office, and died of a heart
attack. He was 51. In 1977 Maxwell was ranked the No. 3 marathon runner in the world by
Track and Field News. Maxwell and his wife Jennifer, a nutritionist, co-founded PowerBar, the
popular energy bar company in 1986 and began by selling PowerBars out of their kitchen. Over
the next decade, the Berkeley, California-based firm grew to $150 million in sales and 300
employees. In March 2000, the couple sold the company to Nestle SA for a reported $375 million.
Maxwell is survived by his wife and five children

30. Robert Palmer 1949 - 2003, the British rock singer died suddenly of a heart attack at age 54 at the
luxury Paris Warwick Hotel on September 25th after a calm night of dinner and a movie. The
singer had received a clean bill of health from his doctors in Switzerland just a few weeks earlier.
Palmer began his career at the age of 19 singing with the Alan Bown Set and a soul group, Vinegar
Joe, before going solo in 1974. He became known for slick videos and a clever combination of rock,
R&B and reggae sounds with hit singles including "Simply Irresistible", "I Didn't Mean to Turn
You On", and the Grammy winning "Addicted to Love". The "Addicted to Love" video, featuring
a sharply dressed Palmer flanked by miniskirted models, became one of early MTV's most-played
clips. Palmer is survived by his companion of 20 years Mary Ambrose and two children

31. Miguel Contreras 1953 - 2005, the son of migrant farmworkers who grew to be one of the nation's
most powerful urban labor leaders was stricken by a sudden heart attack on the way to a meeting on
Friday May 6. Contreras began working the fields of California's fertile Central Valley at age 5. By
age 17, he was leafleting supermarkets on behalf of the national grape boycott called by Cesar
Chavez's then-fledgling United Farm Workers of America. He joined the Los Angeles County
Federation of Labor in 1993. In 2000, he helped lead a strike by Los Angeles janitors, many of them
poor immigrants, against building owners. The work stoppage ended with a new contract that was
touted as a model for labor organizations across the country. That year he also played a key behind-
the-scenes role in resolving the Los Angeles County transit strike that paralyzed public
transportation for over a month. At one point, he publicly rejected what the Metropolitan
Transportation Authority had characterized as its final offer, calling it "cheap" and denouncing it as
an attack on "core middle class jobs." Later, he brought in the Rev. Jesse Jackson as a mediator
when it appeared negotiations had broken down. At the time of his death, Contreras was leader of
the L.A. County Federation of Labor, AFL-CIO, an umbrella organization representing 345 local
unions with political clout extending from Los Angeles to the state Capital and beyond. Contreras is
survived by his wife, fellow labor organizer Maria Elena Durazo, and two sons, Michael and Mario.

32. Case #8:
What arrhythmia is present in this elderly
woman with a history of mitral valve
replacement for rheumatic mitral valve
disease?
• Atrial flutter
• Atrial fibrillation
• Junctional rhythm
• NSR with frequent APC’s
• MAT

33. •Atrial flutter
•Atrial fibrillation
•Junctional rhythm
•NSR with frequent APC’s
•MAT

34. b) The patient had long standing atrial
fibrillation. There are no discrete P
waves which excludes sinus rhythm or
multifocal atrial tachycardia. The erratic
irregular oscullatory baseline with an
erratic ventricular response is typical of
atrial fibrillation. No flutter waves are
seen. The scooping of the ST-T waves
in the inferolateral leads are consistent
with digitalis effect.

35. Case #9:
Which of the following statements about this EKG from a
23 y.o. woman with chest pain is correct?
• The EKG is normal
• It shows RVH
• It shows LVH
• It suggests severe hypokalemia
• It suggests severe hypocalcemia

36. •The EKG is normal
•It shows RVH
•It shows LVH
•It suggests severe hypokalemia
•It suggests severe hypocalcemia

37. a) The ECG shows sinus rhythm at a rate of about
60/min and is completely within normal limits. The
electrical axis (about +50 degrees) and basic
intervals (PR, QRS and QT) are all normal. The P
waves are normal. The QRS complexes have a
normal morphology. The precordial leads show
normal R wave progression (transition zone
between V2 and V3). The ventricular
repolarization (ST-T complex) is physiologic (with
a normal QT interval) making severe hypokalemia
or hypocalcemia unlikely.
Severe hypokalemia generally causes
repolarization (QT-U) prolongation (usually with
flat T waves and sometimes ST sagging). Severe
hypocalcemia prolongs the plateau phase of the
ventricular action potential, associated QT
prolongation due to a stretched out ST segment.

38. Case #10
A 78-year-old man was brought to the Emergency
Department. His wife noted that he had a fever and was
more difficult to rouse this morning. All of the following
statements about his ECG are true EXCEPT:
a) The rhythm is sinus tachycardia
b) The PR interval is borderline prolonged
c) There is a complete left bundle branch block
d) There is left atrial abnormality
e) There is borderline low voltage in the limb leads

39. The rhythm is sinus tachycardia
b) The PR interval is borderline prolonged
c) There is a complete left bundle branch block
d) There is left atrial abnormality
e) There is borderline low voltage in the limb leads

40. The rate is approximately 100 beats per minute, and
there are upright P waves in lead II, fulfilling the criteria
for sinus tachycardia. The PR interval is slightly
prolonged at 0.21 second (normal PR < 0.20 second),
especially in light of the patient’s tachycardia. The P
wave is also wide in lead II (normal duration <0.12
second) and has a large negative component in lead V1
(normal depth <1 mm and width < 0.04 second). These
characteristics indicate left atrial abnormality (LAA.) The
QRS voltage in the limb leads just meets the criteria for
low voltage (< 5 mm in all limb leads). There is no
left bundle branch block (LBBB.) The criteria for
complete LBBB include:1. QRS duration > 0.12
second2. A wide deep QS complex in V1-3 and a wide
tall R wave in V6.

41. Additional comments: Even a mild sinus tachycardia at rest,
especially in an elderly individual, may signal a major abnormality.
Generally, sinus tachycardia results from conditions that either
increase sympathetic tone or decrease vagal tone. Here is a partial
differential diagnosis for resting sinus tachycardia. Can you think of
other causes?
1. Fever, infection, septic shock
2. Volume depletion (blood loss, dehydration, pancreatitis,
diarrhea, vomiting)
3. Anxiety, pain, excitement
4. Endocrine disorders (hyperthyroidism, pheochromocytoma)
5. Anemia
6. Pulmonary embolism
7. Acute myocardial infarction with pump dysfunction
8. Stimulants, such as nicotine, caffeine, cocaine, ecstasy,
methamphetamine, ephedra, and some antidepressants
9. Anticholinergics, such as atropine
This patient was diagnosed with a urinary tract infection and
treated with antibiotics.

42. Important!
Never ignore a sign, symptom, or
lab test you can’t explain.

43. Case #11
A 21-year-old man presents to the Emergency
Department after having a witnessed seizure.
All of the following statements about this ECG
are true EXCEPT:
a) The QRS axis is within normal limits
b) The rhythm is sinus tachycardia
c) The QT interval is normal for the rate
d) There is no evidence of left ventricular
hypertrophy
e) There is a complete right bundle branch
block

44. a) The QRS axis is within normal limits
b) The rhythm is sinus tachycardia
c) The QT interval is normal for the rate
d) There is no evidence of left ventricular hypertrophy
e) There is a complete right bundle branch block

45. e) There is a complete right bundle branch block
The QRS axis is normal at approximately +70 The rate
is approximately 110 beats per minute, and there are
upright P waves in lead II, fulfilling the criteria for sinus
tachycardia. The QTc interval is normal at 0.37 second
(normal QTc < 0.44 second). There is no ECG evidence
of left ventricular hypertrophy (LVH), such as prominent
voltage in the chest leads, T wave inversions in leads
with tall R waves, left axis deviation, left atrial
abnormality, or a left ventricular conduction delay. There
is no right bundle branch block (RBBB.) The criteria for
complete RBBB include:1. QRS duration > 0.12
second2. In V1, an rSR complex with a wide terminal R
wave3. In V6, a qRS complex with a wide S wave

46. Additional comments:
Changes in heart rate have long been noted to
occur during seizures, both partial and
generalized. While sinus bradycardia and even
sinus arrest have been described infrequently,
sinus tachycardia is a common occurrence
during seizure activity. Other rhythm
abnormalities have also been reported, though
rarely, and include atrial and ventricular
premature depolarizations, atrial fibrillation,
and torsade de pointes.

47. Case #12
A 67-year-old man is admitted to the hospital
for a large abscess in his lower abdomen with
surrounding cellulitis. Which of the following
statements about his admission ECG is (are)
correct:
a) The rhythm is sinus tachycardia
b) There is right axis deviation
c) There is a complete right bundle branch
block
d) a and c
e) All of the above

48. a) The rhythm is sinus tachycardia
b) There is right axis deviation
c) There is a complete right bundle branch block
d) a and c
e) All of the above

49. d) a and c
The rate is approximately 100 beats per minute, and
there are upright P waves in lead II, fulfilling the criteria
for sinus tachycardia. His tachycardia is likely related to
pain and to his infection. The QRS axis is -15
borderline left axis. Frank left axis deviation is usually
defined by an axis between -30 and -90 Finally, there is
a complete right bundle branch block (RBBB). The
criteria for complete RBBB include:
1. QRS duration > 0.12 second
2. In V1, an rSR’ complex with a wide terminal R wave
3. In V6, a qRS complex with a wide S wave

50. Additional comments:RBBB may be seen in normal hearts but
is usually associated with an underlying pathology. Conditions
such as Chronic Obstructive Pulmonary Disease (COPD),
pulmonary hypertension, atrial septal defect (ASD), or
pulmonic stenosis may, in the long run, result in RBBB
because of the hypertrophy that occurs in response to
pressure or volume overloads. The conduction systems of
aging hearts may also undergo degenerative changes, causing
RBBB in the absence of any other pathology. Occlusion of the
left anterior descending artery (LAD), causing an acute
anterior myocardial infarction, can also cause RBBB because
the LAD typically supplies the proximal right bundle. The
lesions causing RBBB typically occur in the proximal right
bundle, though they can also occur at the level of the
moderator band and in the terminal portion of the right
bundle.Also note the T wave inversions in leads V1 and V2. T
wave inversions in leads with tall R waves are typical in RBBB
and are called secondary changes. Since depolarization of the
right ventricle is delayed with RBBB, repolarization is delayed
as well. This altered sequence changes the direction of the
repolarization vector, resulting in T wave inversions in leads
with terminal R waves. In contrast, primary T wave
abnormalities reflect an intrinsic disturbance of the action
potentials, which may occur with ischemia, electrolyte
abnormalities, or drug toxicity.This patient had his abscess
drained under anesthesia. His cellulitis was treated with
antibiotics and improved.

51. Aside:
Who invented the EKG machine
anyway?

52. Willem Einthoven

53. Willem Einthoven was born on May 21, 1860 in the city of Semarang on the island of
Java in Indonesia. His father was a physician, but died when Willem was only a
child. After his father's death, his mother moved back to the Netherlands with
young Willem. In 1870, the family settled in the city of Utrecht, where Willem
finished his education. In 1885, he earned a medical degree from the University of
Utrecht and was given a position as a professor at the University of Leiden in 1886.
When he wasn't teaching, he spent a lot of time researching various medical
inventions. At that time, doctors knew that the heart produced electrical impulses.
However, the electronic equipment did not exist to accurately measure the heart
rate or view the amplitude of the electrical impulses. In 1901, Einthoven sought to
solve this problem using a rather crude method. Einthoven's method for measuring
the waveform of the heart used a "string galvanometer". Essentially it used a thin
conductive wire, which ran between two electromagnets. The wire was connected to
electrodes on the patient's chest and would move between the electromagnets
when a current passed through it (indicating a heartbeat). By shining a light on the
wire and placing photographic film underneath the wire, Einthoven was able to
record a curve showing the amplitude of the patient's heartbeat. While Einthoven's
machine was very crude, it was able to record the same signal that we see today
using modern heart monitors. His machine required five people to run it and
weighed in at six hundred pounds. He called it the electrocardiogram (ECG/EKG).
In addition to inventing the machine, Einthoven also named the traditional
deflections of a normal ECG waveform, using the letters P, Q, R, S, and T. He also
contributed to the medical field by measuring the waveforms produced by various
cardiovascular disorders. These irregular rhythms have since become known as
arrhythmia and modern devices are able to automatically detect such conditions.
In 1924, Einthoven was awarded the Nobel Prize in Medicine for his invention of the
ECG machine. Einthoven died on September 29, 1927 in the city of Leiden.

54. Snap Quiz:
What famous French novelist
was born on this day in 1804?
Hints: she took a male
pseudonym, had affairs with
Alfred de Musset (who had aortic
regurgitation and hence de
Musset’s sign) and with Chopin.

55. George Sand

56. Please remember, Jeopardy
looms in late August…