This week we review the answers to questions 7-14 from the 5th annual UMEM Residency ECG Competition. Make sure to attempt to answer the questions before clicking the red box to reveal the answers and teaching pearls!
Video review of each ECG Case:
Key Teaching Points
Question 7. A 62-year-old male with history of CAD presents with palpitations. BP is 115/60. He has no pain, minimal dyspnea, clear lungs, and normal mental status. Electrolytes are normal. What is the ECG diagnosis? (1 point) What is the DRUG of choice? (1 point)
Ventricular Tachycardia (VT)
- Sustained VT
- Rate > 120-130
- Lasts at least 30 seconds or produces hemodynamic instability
- Treatment with meds or shock
- Non-sustained VT (Correct Answer)
- Rate > 120-130
- Lasts < 30 seconds, no associated hemodynamic instability
- Key to treatment is to look for and treat underlying cause
- Cardiac ischemic, hypoxia, electrolyte abnormalities, PE, etc.
- Cardiac ischemia may induce sustained or non-sustained monomorphic VT in the presence of a myocardial scar
- Empiric antiarrhythmic therapies are probably not indicated. No antiarrhythmic drug is suitable for primary prevention of cardiac death except for beta blockers
Question 8. A 37-year-old man presents with chest pain and the ECG below. What is the diagnosis (2 points)
Large pulmonary embolism! There is right axis deviation, sinus tachycardia, ST-segment elevation in aVR, and T-wave inversions in anterior and inferior leads. Pay attention to axis, as right axis deviation can help distinguish massive PE from STEMI.
Question 9. A 31-year-old male presents after a near-syncopal episode. His ECG is shown below. What is the diagnosis (1 point) What is the diagnostic test of choice (1 point) The patient insists on being discharged but will follow up with cardiology in 3 days. What is the optimal outpatient management until follow up? (1 point)
Hypertrophic obstructive cardiomyopathy (HOCM)
- ECG abnormalities present in 85-93%
- Deep narrow “dagger like” Q-waves in inferior, lateral leads
- High left ventricular voltages
- Left atrial enlargement is most common
- Tall R wave in V1 (mimics posterior MI)
- Definitive diagnosis – Doppler ECHO
- Can also help to assess severity of obstruction at rest and with provocative maneuvers
- Treatment
- Beta blockers and minimization of exertion
Question 10. A 54-year-old man presents with chest pain and the ECG noted below. What is the full ECG diagnosis? (2 points)
Sinus rhythm with inferior and right ventricular STEMI
Question 11. A 50-year-old woman presents with mild dyspnea. Nurses noted ~ 10 seconds of an unusual rhythm disturbance on the monitor and they obtained a 12-lead ECG off the monitor, noted below. What is the diagnosis? (1 point) What would be the treatment if this finding persisted? (1 point)
Artifact, no treatment necessary.
Question 12. A 58-year-old man presents with chest pain and the ECG noted below. What is the full ECG diagnosis? (3 points)
Sinus Tachycardia with Mobitz I AV conduction, inferior and posterior STEMI
Question 13. A 64-year-old male presents with palpitations and lightheadedness. ECG is below. What is the optimal treatment? (2 points)
Treatment for hyperkalemia. The QRS is too wide and ventricular rate too slow to be ventricular tachycardia.
Question 14. A 65-year-old woman presents after a syncopal episode. with palpitations and lightheadedness. ECG is below. What is the optimal treatment? (2 points)
Sinus tachycardia with complete heart block and junctional escape rhythm, left posterior fascicular block with inferior-lateral ischemia.
Notes: Questions for Amal? Email him at amalmattu@comcast.net or find him on Twitter @amalmattu.
Regarding question 12, can you comment on the significance – if any – of the change in the QRS morphology occurring along the lead II strip? It seems the first P-wave leads to a slightly different QRS morphology than subsequent conducted P-waves. What is the physiological basis for that consistent change in QRS morphology?
Is the intraventricular conduction delay in question 12 a LPFB? Small q inferiorly, possibly small r aVL, then R waves inferiorly with S in aVL and probably I (but hidden by the reciprocal ST depression). The RWP in aVF looks delayed, and the axis is inferior… Does it meet criteria?
Question 14. Playing devil’s advocate… Don’t you need to exclude other causes of RAD before settling on the rare diagnosis of an isolated LPFB?
RAD + S-wave in I, +aVR STE (the only fully seen complex appears to have this), and inferolateral TWI/ST depression. This sounds a lot like RV strain. PE? Other cause of pulmonary HTN? Other cause of RV strain?
There appears to be a little positive deflection at the end of the QRS in V1 and V3… Epsilon wave? There is only TWI in V3 to fit with this, but there is a prolonged S-wave upstroke in V2 and borderline wide QRS complexes.
The patient presented with syncope… so both AVRC and PE fit the stem… Thoughts?