Learning Medicine with ME

🔺1⃣0⃣9⃣ #150_ECG ANSWER : ✅ The ECG shows: • Variable QRS rate (16-60/min) • No P waves • No irregular baseline to suggest atrial fibrillation • As far as can be ascertained from the rhythm strip, normal QRS complexes and T waves ✅ تفسیر بالینی: This is the 'sick sinus syndrome' or 'sinoatrial disease'. The record shows a 'silent atrium' with a variable junctional escape rhythm. The palpitations described by the patient are probably due to a paroxysmal supraventricular tachycardia, so he probably has the 'bradycardia-tachycardia' variant of sinoatrial disease. ✅ چه باید کرد؟ Ambulatory ECG tape-recording will confirm the cause of the patient's palpitations. Even though his bradycardia is asymptomatic, he will need a permanent pacemaker because anti-arrhythmic agents given for the tachycardia may make his bradycardia worse. ✨ Sinoatrial disease with a 'silent atrium' and junctional escape. @Learning_Medicine_with_ME

🔻1⃣0⃣9⃣#150_ECG This is a continuous rhythm strip (lead II) from a 25-year-old man who complained of episodes of fast, regular, palpitations associated with breathlessness and dizziness. There were no abnormalities on examination other than a slow and irregular pulse, and apart from the rhythm shown here, the ECG was normal. What is the diagnosis and how can his problem be treated? @Learning_Medicine_with_ME

🔺1⃣0⃣8⃣ #150_ECG ANSWER : ✅ The ECG shows: • • Broad complex tachycardia at about 180/min • No P waves visible • Left axis • QRS duration about 140 ms • The fourth and fifth QRS complexes are narrow • QRS complexes are probably concordant (in the chest leads all point upwards) though it is difficult to be certain ✅ تفسیر بالینی: Broad complex tachycardias may be ventricular, supraventricular with bundle branch block, or may be due to a Wolff-Parkinson-White syndrome. We have no ECG from this patient recorded when she was in sinus rhythm, which is always the most helpful thing in deciding between these possibilities. The complexes are not very wide, which would be consistent with a supraventricular origin wit aberrant conduction, but the left axis and (probable) concordance point to ventricular tachycardia. The key is the two narrow complexes near the beginning of the record: these are slightly early and are probably capture beats. They indicate that with an early supraventricular beat the conducting system can function normally; by implication, the broad complexes must be due to ventricular tachycardia. ✅ چه باید کرد؟ An elderly patient with heart failure is more likely to have ischaemic disease than anything else, but all ther possible causes of heart failure must be considered. The sudden onset of an arrhythmia could be due to a myocardial infarction. Pulmonary emboli can cause sudden arrhythmias, though these are more often supraventricular than ventricular. It is important to consider whether this rhythm change is related to treatment, either because of an electrolyte imbalance or the pro-arrhythmic effect of a drug the patient is taking. ✨ Ventricular tachycardia @Learning_Medicine_with_ME

🔻1⃣0⃣8⃣#150_ECG A 70-year-old woman, admitted to hospital because of increasing heart failure of uncertain cause, collapsed and was found to have a very rapid pulse and a low blood pressure. This is her ECG. She recovered spontaneously. What is this rhythm, and what would you do? @Learning_Medicine_with_ME

🔺1⃣0⃣7⃣ #150_ECG ANSWER : ✅ The ECG shows: • Atrial fibrillation • Irregular QRS complexes with a ventricular rate of up to 200/min • Normal axis • Height of R waves in lead V6 plus depth of S waves in lead V2 is greater than 35 mm, suggesting left ventricular hypertrophy • Otherwise normal QRS complexes, apart from an RSR pattern in lead VF • ST segments depressed in leads V4-V6, suggesting ischaemia • Normal T waves ✅ تفسیر بالینی: Atrial fibrillation with an uncontrolled ventricular rate. The ischaemic changes in leads V4 and V5 are probably related to the heart rate. ✅ چه باید کرد؟ Ischaemia may have been the cause of the atrial fibrillation, or the rapid ventricular rate itself may be responsible for the ischaemic changes. Ischaemia is not a likely primary diagnosis in a 50-year-old woman, and the things to think about are rheumatic heart disease (particularly with mitral stenosis), thyrotoxicosis, alcoholism, and other forms of cardiomyopathy. Immediate treatment of heart failure with diuretics and intravenous nitrates may be necessary, but the ventricular rate is best controlled by digoxin, which can be given intravenously if necessary. DC cardioversion may be necessary if the patient is in severe heart failure, but it is best to establish the underlying cause of the atrial fibrillation first if possible. Remember that a patient with atrial fibrillation probably needs long-term anticoagulants. ✨ Atrial fibrillation with a rapid ventricular rate and ischaemic changes. @Learning_Medicine_with_ME

🔻1⃣0⃣7⃣#150_ECG A 50-year-old woman came to the A & E department because of the sudden onset of palpitations and severe breathlessness. What abnormality does this ECG show, and what conditions might be responsible? @Learning_Medicine_with_ME

🔺1⃣0⃣6⃣ #150_ECG ANSWER : ✅ The ECG shows: • • Sinus rhythm • Normal axis • Normal QRS complexes • Raised ST segments in leads I, VL, V2-V6 ✅ تفسیر بالینی: The ECG has the classic appearance of an acute anterolateral myocardial infarction. ✅ چه باید کرد؟ Since this patient's chest pain began more than 24 h ago, thrombolysis is not indicated. The breathlessness suggests that he may have developed left ventricular failure, and he must be admitted to hospital and treated with diuretics and if necessary intravenous nitrates to induce vasodilation. The patient will need long-term treatment with an angiotensin-converting enzyme inhibitor: the best time to begin treatment is a matter for debate but it should be within 2 or 3 days. He will also need long-term treatment with aspirin as a prophylactic against further infarction. ✨ Acute anterolateral myocardial infarction. @Learning_Medicine_with_ME

🔻1⃣0⃣6⃣#150_ECG A 48-year-old man is seen in the A & E department with a history of severe chest pain which began 24 h previously, but has now cleared. He is now breathless. What does this ECG show and what treatment is needed? @Learning_Medicine_with_ME

🔺1⃣0⃣5⃣ #150_ECG ANSWER : ✅ The ECG shows: • Sinus rhythm, rate 34/min • Normal axis • Bifid P waves, best seen in the lateral leads • Small narrow Q waves in the lateral leads • Normal QRS complexes • Peaked T waves ✅ تفسیر بالینی: Sinus bradycardia can be due to physical fitness, vagal overactivity or myxoedema. In a hypertensive patient, beta-blocker treatment is the likely explanation. The bifid P waves may indicate left atrial hypertrophy ('P mitrale'), but can be normal. The lateral Q waves are normal, representing septal depolarization. The peaked T waves could be due to hyperkalaemia but are more often a normal variant. ✅ چه باید کرد؟ Check the serum potassium level. ✨ Normal ECG. @Learning_Medicine_with_ME

🔻1⃣0⃣5⃣#150_ECG This ECG was recorded from a 50-year-old man who had hypertension but was otherwise well. Despite showing four possible 'abnormalities', is the trace actually normal? @Learning_Medicine_with_ME

🔺1⃣0⃣4⃣ #150_ECG ANSWER : ✅ The ECG shows: • Broad complex rhythm at 90/min • No P waves • Marked left axis • QRS duration 160 ms • All chest leads show a downward QRS complex (concordance) ✅ تفسیر بالینی: If the heart rate were fast there would be little difficulty in recognizing this as ventricular tachycardia, and this rhythm used to be called 'slow VT. It is, however, an accelerated idioventricular rhythm. ✅ چه باید کرد؟ This rhythm is quite commonly seen in patients with an acute myocardial infarction, and indeed is not uncommon in ambulatory ECG records from normal people. It never causes problems, and it is important not to attempt to treat it: suppressing any 'escape' rhythm may lead to a dangerous bradycardia. ✨ Accelerated idioventricular rhythm. @Learning_Medicine_with_ME

🔻1⃣0⃣4⃣#150_ECG This ECG was recorded from a 45-year-old man, who had been admitted to a coronary care unit with a myocardial infarction and who was recovering well. What is the rhythm, and what would you do? @Learning_Medicine_with_ME

🔺1⃣0⃣3⃣ #150_ECG ANSWER : ✅ The ECG shows: • Sinus rhythm • Normal axis • Normal QRS complexes apart from narrow Q waves in lead VL • Marked T wave inversion in leads I, VL, V2-V6 ✅ تفسیر بالینی: If this ECG had been recorded from a middle aged man presenting with acute chest pain, the diagnosis would be an anterior non-Q wave infarction, or possibly an early lateral Q wave infarction. The ECGs of athletes can show ST segment and T wave changes due to left ventricular hypertrophy, but anteroseptal T wave inversion of this degree in a healthy young man almost certainly represents hypertrophic cardiomyopathy. ✅ چه باید کرد؟ Echocardiography will confirm the diagnosis. Ambulatory ECG tape-recording will show whether the patient is having ventricular arrhythmias. He must not play competitive sports and his close relatives should be screened. ✨ Probable hypertrophic cardiomyopathy. @Learning_Medicine_with_ME

🔻1⃣0⃣3⃣#150_ECG This ECG was recorded as part of a routine examination of a healthy 25-year-old professional athlete. There were no abnormal physical findings. What does it show and what would you do? @Learning_Medicine_with_ME

🔺1⃣0⃣2⃣ #150_ECG ANSWER : ✅ The ECG shows: • Sinus rhythm • Normal PR interval • Left axis deviation • Right bundle branch block ✅ تفسیر بالینی: The combination of left axis deviation (also called left anterior hemiblock, because it is due to block of the anterior fascicle of the left bundle branch) and right bundle branch block is called bifascicular block. Atrioventricular conduction depends on the posterior fascicle of the left bundle branch. ✅ چه باید کرد؟ Progression to complete block can occur but is relatively rare. In the absence of symptoms, standard UK practice would be not to insert a permanent pacemaker. ✨ Left axis deviation and right bundle branch block - bifascicular block @Learning_Medicine_with_ME

🔻1⃣0⃣2⃣#150_ECG This ECG was recorded from a fit 60-year-old man at a routine medical examination. What does it show and what would you recommend? @Learning_Medicine_with_ME

🔺1⃣0⃣1⃣ #150_ECG ANSWER : ✅ The ECG shows: • Sinus rhythm • Right axis deviation • Normal QRS complexes except for an RSR pattern in lead V2 and deep S waves in lead V6 • Inverted T waves in leads V1-V4 ✅ تفسیر بالینی: The right axis deviation, the deep S waves in lead V6 ('clockwise rotation') and the inverted T waves in the chest leads are all characteristic of marked right ventricular hypertrophy: the only missing feature is the absence of dominant R waves in lead V1. Note how the T wave inversion is at a maximum in lead V1 and becomes progressively less marked from lead V2 to V4. ✅ چه باید کرد؟ In the context of a delivery 3 months previously, this ECG pattern of right ventricular hypertrophy almost certainly indicates multiple small pulmonary emboli causing pulmonary hypertension. A lung scan would confirm this diagnosis and anticoagulants are needed urgently. ✨ Right ventricular hypertrophy. @Learning_Medicine_with_ME

🔻1⃣0⃣1⃣#150_ECG A 32-year-old woman, who had a normal pregnancy and delivery 3 months previously, was seen in the out-patient department complaining of breathlessness and dizziness on exertion. She had had no chest pain. Does her ECG help with her diagnosis and treatment? @Learning_Medicine_with_ME

🔺1⃣0⃣0⃣ #150_ECG ANSWER : ✅ The ECG shows: • Atrial fibrillation with a ventricular rate of 50/min • QRS duration prolonged at 160 ms • Prominent 'J' waves, best seen in leads V3-V6 • Widespread but non-specific ST/T changes ✅ تفسیر بالینی: The atrial fibrillation may or may not be related to her stroke - she may have had a cerebral embolus, or she may have both coronary and cerebrovascular disease. The slow ventricular rate and the 'J' waves indicate hypothermia, and her core temperature was 25°C. ECGs from hypothermic patients seldom show 'J' waves as clearly as this because there are too many artefacts due to shivering - but this patient was too cold to shiver. She did not survive. ✨ Atrial fibrillation and hypothermia. @Learning_Medicine_with_ME

🔻1⃣0⃣0⃣#150_ECG This ECG was recorded from an 80-year-old woman who had been found unconscious with physical signs suggesting a stroke. Any comments? @Learning_Medicine_with_ME