Ecg masters summit

1. pericarditis – 55 M with ESRD on transplant list presenting with CP and SOB due to uremic
pericarditis (BUN 140 and Cr 7.5). Note the diffuse ST segment elevation attributed to subepicardial ventricular injury and the PR segment depression attributed to subepicardial atrial injury.
2. 2:1 atrio-ventricular block with left-bundle branch block and long QT syndrome – 68 F
presenting with syncope due to torsade de pointes from pause-dependent long QT resulting from 2:1 AV block.
3. ventricular couplets originating from the right ventricular outflow tract – 46 F with a 20 year
history and recent worsening of palpitations and shortness of breath from RVOT VT who underwent successful radiofrequency ablation of an anteroseptal RVOT focus.
4. atrial bigeminy – . 86 asymptomatic F with prior MI. The differential includes sino-atrial exit block
Type I (Wenckebach), but the different morphology of the second P wave makes atrial bigeminy the most likely diagnosis.
5. ventricular tachycardia – 66 F with STEMI s/p LCX stent followed by subacute stent thrombosis.
Note the AV dissociation, fusion beat, and capture beat.
6. focal atrial tachycardia – 58 M with severe lightheadedness due to atrial tachycardia which was
refractory to sotalol who underwent successful radiofrequency ablation of a right atrial focus near the crista terminalis. Note the RBBB aberrancy due to Ashman’s phenomenon.
7. hyperkalemia – 59 F with ESRD who missed 2 days of HD presenting with weakness and a
potassium level of 8.1 mEq/L. Note the pronounced intraventricular conduction delay resembling a RBBB, tall T waves, and prominent S waves in I and lateral precordial leads.
8. Inferior STEMI with RV infarction – 63 M with 100% occlusion of the proximal dominant RCA. 2 SL
NTG given resulted in SBP drop from 140 to 40. Note that RCA involvement (as opposed to LCX involvement) in the setting of inferior infarction is suggested by 1) ST segment depression in aVL, 2) ST elevation in III > II. RV involvement is suggested by ST elevation in lead V1 in 8a and V4R in 8b, but note how V1 in 8b has a tall R wave with ST depression, suggesting a posterior infarction.
9. artifact – 92 M with pacemaker and artifact due to right arm tremor. For full discussion see Wang NC.

10. 2:1 atrial flutter with LBBB – 67 M with DOE and newly diagnosed mixed ischemic/nonischemic

11. second degree type I (Wenckebach) atrio-ventricular block with left-bundle branch block then
third degree heart block – 84 F presenting with progressive DOE.

12. pleural effusion with low voltage – 66 F with metastatic breast cancer with syncope who found to
have a pericardial effusion which yielded > 1L after pericardiocentesis.
13. digitalis toxicity – 76 F with a history of atrial fibrillation on digoxin who was given clarithromycin for
an upper respiratory tract infection (digoxin level >7 ng/dl). Note the ectopic atrial rhythm and accelerated junctional escape rhythm with intermittent conduction from the atrium (comes early). “Scooped” ST segment depressions when the QRS is predominantly positive is a therapeutic effect, however scooping when the QRS is predominantly negative indicates toxicity (as is seen in lead V2). 14. atrial flutter with 1:1 conduction – 55 M with palpitations who was given adenosine. He underwent
cavotricuspid isthmus ablation. Ventricular tachycardia post adenosine infusion for SVT is produced by an unknown mechanism and has no prognostic utility.
15. long QT and polymorphic ventricular tachycardia – 37 F on methadone who coincidentally sought
EP evaluation after reading about the death of Anna Nicole Smith’s son from a combination of methadone and psychiatric medications.
16. Wellens Syndrome – 62 F presenting with CP and found to have a 90% stenosis of her ostial LAD.
ECG characteristics include deep, symmetrical T wave inversions in the precordial leads. First described in de Zwaan C, et al. Am Heart J 1982;103:657-665. Early invasive treatment is mandated as conservative treatment leads to large anterior wall myocardial infarction in 75% of patients.
17. Managed Ventricular Pacing – Asymptomatic M with pacemaker having MVP function. Mode
switching occurs with 2 dropped beats. In this case, second degree Type I (Wenckebach) AV block occurs. In the first tracing, A-pacing resumes; in the second tracing a non-conduced premature atrial contraction leads to 2 dropped beats and mode switching.
18. orthodromic reentrant tachycardia over a left lateral accessory pathway (Wolff-Parkinson-
White Syndrome) – 46 F with palpitations since age 12 but for the first time had an episode which
she could not terminate, requiring emergency department visit where she was given adenosine. She
underwent successful radiofrequency ablation. Note that delta waves are seen primarily with
premature atrial contractions due to decremental properties of the AV node.

19. Right axis deviation with electocardiographic criteria for right ventricular hypertrophy and left
ventricular hypertrophy. – 25 F with a Tetrology of Fallot s/p surgical shunt x2 with right ventricular
hypertrophy and dilated cardiomyopathy with LVEF 45%.

20. pacemaker malfunction – 44 M with pacemaker implantation 4 years ago for conduction disease in
sinus node, AV node, and His purkinje presented with SOB for one week and was found to have a ventricular lead fracture leading to intermittent failure to sense and pace.
21. ventricular tachycardia – 46 F with nonischemic cardiomyopathy and syncope.
22. atrial flutter with third degree heart block – 77 M presenting with a fall and head trauma. On the
second tracing, he had spontaneously converted to sinus rhythm.
23. accelerated idioventricular rhythm – 54 healthy F with pre-op ECG for broken arm after fall (no

24. long QT with “macrovolt” T wave alternans – 66 M with CAD and atrial fibrillation who takes
sotalol intermittently when his AF “bothers him” presented to the ED after syncope. In the ED he had torsade de pointes.
25. atrio-fascicular pathway – 16 M with “WPW” s/p unsuccessful ablation of a postero-septal pathway
in California presents with palpitations and near-syncope. He underwent successful radiofrequency ablation of a right postero-lateral Mahaim fiber.

Source: http://www.cardiologyfellows.northwestern.edu/ecgmaster/spring2007_ans_all.pdf