Cardiology ECG Review
for the ABIM

A 42-year-old man is noted to have a soft S1
on physical examination.
Where’s The “P”
2. Look at QRS
3. Assess ST Segment

A 72-year-old man with a 35-year history of
hypertension is evaluated because of
dyspnea.
What is LVH?

Cornell:



Voltage:


R wave in aVL + S wave in V3
>20 in ♀, >24 in ♂
R wave in V5/V6 + S in V1 > 35mm
Non Voltage Changes:




LAA
LAD
IVCD
Asymmetric ST depression + T wave inversion
A 72-year-old man is noted to have bradycardia alternating
with tachycardia during an orthopedic procedure.
ECG Diagnosis
Atrial fibrillation (AF) is characterized by:
1. Rapid and irregular atrial fibrillatory waves at
a rate of 350 to 600 imp/min
2. An irregularly irregular ventricular response
of 90 up to 170 beats/min
(Can be higher in some pts)
Pitfalls in Diagnosis
1. Fibrillatory waves may be inapparent on the
standard and precordial leads.
2. Fibrillatory and U waves may have sufficient
amplitude to look like P waves.
3. Extracardiac artifacts (eg, 60 cycle/min muscle
tremors as in Parkinsonism) may simulate
fibrillatory waves.
4. Regular R-R interval with AV dissociation or
block with a lower junctional or ventricular
pacemaker assumes control of the ventricles

A 65-year-old woman is evaluated because of
new-onset atrial fibrillation and an embolic stroke.
Echocardiography is performed. What does the
echocardiogram show?
Spontaneous Echo Contrast



Increased RBC aggregation due to
altered LAA flow dynamics and
uncoordinated left atrial systole
Results in smoke-like echoes swirling in
LA: SEC or “smoke” presumed to
proceeding stage to thrombus formation
Seen in 50%- 65% of pts with AF
60-year-old woman with hypertension and diabetes mellitus
is evaluated because of an 8-hour history of substernal
chest pressure associated with dyspnea and diaphoresis.
MI - LOCATION






Anteroseptal: V1-3
Inferior: II, III, F
Anterior: V2-4, or V1-V6
Anterolateral: V4/5-V6, I, aVL
Right Ventricular: ST elevation V4R
Posterior: Tall R waves in V1, R/S ratio in
V1>1
Normal ST elevation (concave)
Early repolarization (concave)
Normal variant with terminal T-wave inversion
LVH
LBBB
Acute HyperK+ AS
MI
Pericarditis
Brugada
AS
RBBB
Marriott, NEJM, 2004.

A 38-year-old woman is evaluated because of palpitations.
She has a childhood history of the acute onset of rapid
regular palpitations that she has learned to terminate with
different vagal maneuvers. A 12-lead electrocardiogram taken
during a period of palpitations is shown. What abnormality is
seen?
Commonly Encountered SVT

Regular


Sinus Tachycardia
PSVT





AVRT
AVNRT
SART
Atrial Flutter
PAT

Irregular




Atrial Fibrillation
MAT
Sinus Tachycardia
with frequent PAC’s
Atrial Flutter with
variable AV block
AVNRT
•
•





Most common SVT
Two pathways within the
AV node
Rates: 120-250BPM
Median age: 32+/-18
P waves often buried within
QRS complex
Inverted P waves in leads I,
II, III and aVF
Pseudo-r’ waves in V1
AVNRT
<70ms

A 76-year-old woman with hypertension and paroxysmal atrial
fibrillation is seen for a follow-up visit. Current medications are
hydrochlorothiazide and digoxin.
Digitalis Toxicity

Classic combo disturbances:


Atrial tachycardia with AV block
Regular, accelerated junctional rhythm in AF

A 65-year-old man is
evaluated because of
lower-extremity
edema and renal
failure.
Echocardiography is
performed. What does
the echocardiogram
show?

A 75-year-old woman who was treated for
heart block 3 years ago is seen for a followup visit.
Pacemaker Codes
Pacing Systems
Pacemaker

An 87-year-old man with a pacemaker implanted for
atrioventricular block is seen in follow-up.

An 80-year-old man underwent implantation of a single-chamber
pacemaker for paroxysmal atrioventricular block 3 years ago. He
now has a cerebrovascular accident.
VVI Mode

Responds to a sensed event.




Time value remaining in interval deleted
Output circuit disabled
Interval ends without a paced event
Commonly used for patients in chronic AF.
VVI Mode
(1)
(2)
(3)
(4)
Ventricular pacing
Ventricular pacing after ventricular escape interval(VV)
Ventricular sensed event, no pacing, VV reset
Ventricular pacing after reset ventricular escape interval

A 60-year-old woman is evaluated because of
palpitations.
Atrial Flutter

Atrial tachycardia typically< 180 bpm





AT usually has isoelectric baseline
Atrial fluttter rates 240-200 bpm
Macroreentrant atrial rhythm with a reentry
circuit involving large area of atrium
Commonly 2:1 AV conduction
Even ratios (2:1, 4:1) much more common
than odd ratios (3:1, 5:1)
Atrial Flutter

Type I or Typical
atrial flutter
More negative in Lead II
Type II
atrial flutter

More positive F waves inferiorly

A 59-year-old man is brought to the emergency
department because of substernal chest pressure of 1
hour's duration.
Heart Block in MI

Inferior MI

Anterior MI:

A 53-year-old woman is evaluated because of
pleuritic chest pain.
Classic Evolution in Acute Pericarditis




Stage 1: Concave ST segment elevation in
almost all leads (no reciprocal ST depression)
Stage 2: ST segments decrease and T wave
amplitude reduces
Stage 3: T waves invert
Stage 4: ECG normalizes
Acute Pericarditis

Look at lead aVR:





ST depression
PR elevation
Sinus Tachycardia
PR depression
Look for electrical alternans

An 84-year-old woman is hospitalized
because of acute coronary syndrome.

A 74-year-old man with ischemic cardiomyopathy and
an implanted cardioverter/defibrillator develops
palpitations and presyncope.
VT- All favor



History: 90% of Ischemic CMP WCT=VT
Axis- “northwest/ right superior”
QRS Duration:






RBBB> 140ms
LBBB> 160ms
Precordial Concordance (esp negative)
AV Dissociation
Fusion beats
Capture beats

A 78-year-old woman is hospitalized
because of pyelonephritis.

A 50-year-old man with severe ischemic
cardiomyopathy is hospitalized because of
syncope.
Bundle Branch Block
QRS> 0.12ms

Left:



Broad monophasic R wave in leads I, V5, or V6
Leads V1-2 reveal QS or rS pattern
Right:


Secondary r’ wave in V1 –o ften an M shape
Wide slurred S wave in I, V5, and V6

A 60-year-old man with hypertension and an evolving
anterior wall myocardial infarction is evaluated in the
emergency department.
Acquired: Polymorphic VT most commonly
precipitated by long-short RR intervals

A 45-year-old male smoker is evaluated because of a 3hour history of substernal chest pressure radiating to the
left arm associated with nausea and vomiting.
A 43-year-old man with congenital heart disease is
evaluated because of progressive dyspnea for the past 3
years.
RVH




Right axis deviation
Tall R wave in V1> 7mm, R/S ratio V1> 1
QRS< 120ms
S wave in in V5/6> 2mm

A 44-year-old woman has hypertension.
AVRT
AVRT
Bypass Tract
BPT is concealed, retrograde
conduction allows Atrial
activation>>AVN conduction>>V
activation>> Retrograde BPT
conduction>> Atrial activation …..
Bypass Tract
Antegrade conduction is evidenced
by Delta wave, atrial activation>>
BPT conduction>> V activation>>
Retrograde AVN conduction >>
atrial activation …..
AVRT

A 52-year-old man is evaluated because of
acute renal insufficiency

An otherwise asymptomatic 72-year-old man
is evaluated because of an irregular pulse
rate detected by his physician.


A 55-year-old man is
evaluated because of
chest pain and
hypotension 5 days
after sustaining a
myocardial infarction.
Echocardiography is
performed.
What does the
echocardiogram show?

A 22-year-old man is evaluated because of
dyspnea.

A 74-year-old man is evaluated because of
exertional fatigue.
Heart Block

Complete Heart Block

AV dissociation



No relationship between P waves and QRS complexes
RR is regular
Second degree AV block: Mobitz Type II


PR remains constant and is either nml or slighlt
prolonged
Ventricular rhythm is irregular because of
nonconducted beats

62-year-old man with hypertension and diabetes mellitus is
evaluated because of substernal chest pressure radiating to
the neck for the past 35 minutes. A 12-lead
electrocardiogram is obtained upon his arrival in the
emergency department.

A 70-year-old woman with hypertension is
seen for evaluation.

A 40-year-old woman is evaluated because of
headaches and muscle cramps.
A 46-year-old woman is evaluated because of palpitations. Her
12-lead electrocardiogram, obtained while she is having typical
symptoms.

A 74-year-old man with a history of prior
myocardial infarction is evaluated because
of palpitations.