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EKG Guidelines Flashcards

1
Q

Define anterolateral MI, age recent or probably acute?

A
  • Pathological Q waves (must be greater than or equal to 30 ms wide and 0.1mV deep in amplitude or QS complex) in anterolateral leads V3-V6
  • Evidence of acute or evolving myocardial injury (i.e. ST-elevation in two contiguous leads greater than or equal to 2mm in men or 1.5mm in women in V3 and/or 1mm in V4-V6)

***Only use this diagnosis when both are present:

  • pathological Q waves
  • ST-elevation are present
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2
Q

What EKG finding can demonstrate “pseudo” anterior MI (q-waves)?

A

LAFB

  • low anterior forces or “pseudo” anterior MI
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3
Q

EKG DDx:

  • Lead I - Inverted P-wave
A
  • PAC’s
  • Atrial Rhythm
    • AT
    • MAT
    • SVT
  • PJC’s
  • PVC’s with retrograde activation
  • Dextrocardia
    • (inverted P-QRS-T in leads I and aVL)
    • (reverse R wave progression in the precordial leads)
  • Reversal of right and left arm leads
    • (inverted P-QRS-T in leads I and aVL)
    • (normal R wave progression in the precordial leads)
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4
Q

Define Inferior MI

A
  • Pathological Q waves in at least in at least 2 inferior leads
  • Evidence of acute or evolving myocardial injury
    • ST elevation greater than or equal to 1 mm in two contingous inferior leads
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5
Q

Define LAFB

A
  • LAD ( -45 to -90)
  • qR complexes in I and aVL
  • rS complexes in III
  • Prolonged R wave peak time in aVL ( > 45 ms)
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6
Q

What are EKG conditions/changes that interfere with the EKG diagnosis of posterior MI?

A
  • RVH
  • WPW
  • RBBB
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7
Q

Define ST and/or T wave abnormalities suggesting myocardial ischemia?

A
  • Greater than 1mm of horizontal or downsloping ST-T segment depression

and/or

  • T wave inversion greater than or equal to 2mm
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8
Q

How to differentiate the direction of macro re-entry in atrial flutter?

A
  • Flutter wave amplitude in leads aVF and I
    • aVF / lead I > 2.5 = counter-clockwise
    • aVF / lead I < 2.5 = clockwise
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9
Q

Aberrantly conducted PAC’s are most often this pattern

A

RBBB

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10
Q

What is the differential for irregularly, irregular SVTs?

A
  • Differential Dx:
    • MAT
    • ST with PAC’s (frequent)
    • A-fib (coarse)
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11
Q

What is required to code for RAE?

A

NSR

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12
Q

What are additional pitfalls to avoid in presence of LAFB?

A
  • May result in a false-positive diagnosis of LVH based on voltage criteria in lead I or aVL
  • Can mask presence of inferior wall MI
  • Rarely seen in normal hearts
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13
Q

True/False:

Posterior MI is usually seen in the setting of acute inferior or inferolateral MI, but may also occur in isolate lateral MI

A

True

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14
Q

Define 2nd degree AV block - Mobitz II?

What are the associated features?

A
  • Regular sinus or atrial rhythm with intermittent non-conducted P waves and no evidence of PAC’s
  • Constant P-R interval exists with all conducted beats
  • The R-R interval of non-conducted beat is equal to two P-P intervals
  • Site of block: more commonly (80%) distal to the AV node (intra- or infra-Hisian) –> wide QRS ( > 120ms)
  • Often show signs of conduction system disease (BBB or fascicular block)
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15
Q

Define left anterior fascicular block (LAFB) on EKG

A
  • Left axis deviation (usually more negative than -45)
  • Slight widening of the QRS complex
  • Prominent S wave in V5 and V6
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16
Q

Define Anterior or anteroseptal, age recent or probably acute?

A
  • Pathological Q waves (must be greater than 30ms wide and 0.1mV deep in amplitude or QS complex) in anterior (V3-V4) or anteroseptal (V1-V3) leads; Q wave width may only be 20ms wide in V2-V3
  • Evidence of acute or evolving myocardial injury (i.e. ST-elevation in two contiguous leads greater than or equal to 2mm in men or 1.5mm in women in V2-V3 and/or 1mm in other anterior or atneroseptal leads)

***Only use this diagnosis when both are present:

  • pathological Q waves
  • ST-elevation are present
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17
Q

What is the diagnosis that should be considered?

  • Atrial flutter
  • 3rd degree heart block
  • Junctional tachycardia
A

Digoxin toxicity

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18
Q

What is the EKG criteria for LPFB?

A
  • RAD ( > +90 degrees)
  • Small R waves with deep S waves (rS complexes) in leads I and aVL
  • Small Q waves with tall R waves (qR complexes) in leads II, III, aVF
  • QRS normal or slightly prolonged
  • Prolonged R wave peak time in aVF
  • Increased QRS voltage in limb leads
  • No evidence of RVH or any other cause of RAD
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19
Q

Define posterior MI

A
  • V2-V3
    • dominant R waves (R wave > S wave with and R wave duration ≥ 40 msec)
    • ST-depression ≥ 1 mm with upright T-waves
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20
Q

What are the EKG criteria for LAFB?

A
  • LAD (usually between -45 and -90 degrees)
  • Small Q waves with tall R waves (qR complexes) in leads I and aVL
  • Small R waves with deep S waves (rS complexes) in leads II, III, aVF
  • QRS duration normal or slightly prolonged (80-110ms)
  • Prolonged R wave peak time in aVL > 45ms
  • Increased QRS voltage in the limb leads
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21
Q

Define 1st degree AV block?

When is this seen (acquired)?

A
  • P-R interval greater than or equal to 200msec
  • Each P-wave is followed appropriated by a QRS
  • High vagal tone (during sleep)
  • Treatment with BB or CCB’s
22
Q

What are causes of LBBB?

A
  • CAD
  • HTN
  • Aortic stenosis
  • Anterior MI
  • Dilated Cardiomyopathy
  • Primary degenerative disease of the conducting system (Lenegre disease)
  • Hyperkalemia
  • Digoxin toxicity
23
Q

Why does SVT typically occur with aberrant conduction in RBBB morphology?

A
  • Right bundle has a longer refractory period than the left bundle
  • Aberrant conduction usually travels down the left bundle
  • Resulting in QRS morphology with RBBB pattern
24
Q

What are the EKG diagnostic criteria of LBBB?

A
  • QRS duration > 120ms
  • Dominant S wave in V1
  • Broad monophasic R wave in lateral leas (I, aVL, V5-V6)
  • Prolonged R wave peak time > 60ms in left precordial leads (V5-V6)
  • Associated features
    • Appropriate discordance
      • ST segments and T waves always go in the opposite direction to the main vector of the QRS complex
    • Poor R wave progression the precordial leads
    • Left axis deviation
25
Define EKG criteria for WPW?
* short PR interval ( \< 120ms in adults and \< 90ms in children during sinus rhythm) * Slurring of QRS complex (delta wave), resulting in the QRS being \> 120 ms in adults and \> 90 ms in children * widened QRS results from fusion of two electrical impulses, one through the normal AV node and the other through the bypass tract * Secondary ST-T wave changes * ST-T segment deviation opposite in direction of main QRS deflection * Pseudo-infarction pattern can be seen in up to 70% of patients * due to negatively deflected delta waves in the inferior/anterior leads ("pseudo-Q waves"), or as a prominent R wave in V1-V3 (mimicking posterior infarction)
26
Differentiate MAT from: * ST with PAC's * A-fib
* MAT (from ST with PAC's) * will not demonstrate a **single, dominant, atrial pacemaker** * MAT (from A-fib) * **isoelectric baseline between P-waves**
27
# Define 3rd degree (complete) AV block? When can this be seen? adenosine
* Complete failure of atrial impulses to pass through the AV node and stimulate ventricular activity * Results in constant P-P intervals, but the atrial and ventricular rhythms are independent of each other * Atrial rate is typically faster than the ventricular rate, as the ventricular rate is driven by either a junctional rhythm, ventricular escape complex, or a ventricular pacemaker * MI, degnerative diseases (Lev's, Lenegre's), infiltrative diseases (sarcoidosis, amyloidosis), digitalis toxicity, endocarditis, marked hyperkalemia, Lyme disease, myocardial contusion, acute rheumatic fever, severe valvular disease.
28
EKG DDx: * Lead II - Multiple P wave morphologies
* Wandering atrial pacemaker (rate \< 100 bpm) * MAT (rate \> 100 bpm) * Sinus or atrial rhythm with multifocal PAC's
29
# Define 2nd degree AV block - 2:1? When can this be seen?
* Regular sinus or atrial rhythm with two P waves for every QRS complex (only every other P wave is conducted) * Can be secondary to Mobitz type I or Mobitz Type II AV block
30
# Define 2nd degree AV block - Mobitz 1 (Wenckebach)? When can this be seen?
* Progressive prolongation of the PR interval until a P wave is blocked * R-R interval of non-conducted beat must be less than 2 times the P-P interval (otherwise, high degree of AV block exists) * Will give the appearance of group beating * Site of block: usually in the AV node * High vagal tone, AV nodal blocking agents (BB, CCB's)
31
Define Inferior MI, age recent or probably acute?
* Pathological Q waves (must be greater than or equal to 30ms wide and 0.1mV deep in amplitude or QS complex) in at least two inferior (II, III, or aVF) leads * Evidence of acute or evolving myocardial injury (i.e. ST-elevation greater than or equal to 1 mm in two congiusou inferior leads) \*\*\*Only use this diagnosis when _both_ are present: * pathological Q waves * ST-elevation are present
32
Describe the different types of WPW
* Type A: positive delta wave in all precordial leads with R/S \> 1 in V1 * Type B: negative delta wave in leads V1 and V2
33
Classic features for a rhythm originating in ventricular myocardium
* Wide QRS ( \> 0.28s) * R wave in lead aVR ("northwest axis") * capture complexes * \> 100 ms from onset of R wave to the nadir of the S wave in \> 1 chest lead * atypical RBBB = R \> R' in V1 * R wave usually \< R'
34
What is the term for rhythm of ventricular origin with HR \< 100 bpm?
AIVR
35
How do you distinguish between: * coarse A-fib * MAT
MAT → isoelectric baseline between P-waves
36
Describe differences in etiologies of QT prolongation:
QT prolongation due to: * **Hypocalcemia → normal T waves** * ST lengthening without a change in T wave duration or morphology * **Medications or Genetic disorders → complex T wave morphology**
37
What is “T-wave memory?" When is it seen?
* TWI's occurring in ECG of patients in their NSR when they had abnormal ventricular activation transiently due to various causes * Causes: * RV pacing * VT * intermittent LBBB * intermittent WPW syndrome
38
Differentiate location of conduction delay in 1st degree AV block
* Narrow QRS * conduction delay typically occurs in the AV node * usually due to: * medications that delay AV conduction (BB, CCB, Digoxin) * normal physiology / High vagal tone (high fitness levels, nausea, pain, sleep) * Wide QRS * may represent conduction delay in the His-Purkinje system * usually in conjunction with RBBB, LAFB, LPFB, LBBB
39
Posterior MI cannot be diagnosed in the presence of this?
RBBB
40
What is one key finding when coding for acute inferior Q wave MI?
aVL * there will virtually always be **reciprocal ST segment depression** * even if the ST segment elevation in other leads is minimal
41
What is one key finding when coding for acute lateral Q wave MI?
aVF * there will virtually always be **reciprocal ST segment depression** * even if the ST segment elevation in other leads is minimal
42
What is required for the diagnosis? * Acute cor pulmonale including pulmonary embolus
* Symptoms of acute decompensation (sudden onset dyspnea, collapse) * EKG findings: * RV strain pattern (ST-depression + TWI in R precordial leads) * Rhythm change (ST, A-fib)
43
When evaluating for signs of acute or active CAD? * ST-T changes suggesting myocardial ischemia
* significant ST depression is observed * often with concomitant inverted or biphasic T waves * but **without abnormal Q waves**
44
When evaluating for signs of acute or active CAD? * ST-T changes suggesting myocardial injury
* ST elevation * with or without abnormal Q waves
45
When evaluating for signs of acute or active CAD? * Old or age indeterminate
* abnormal Q waves are observed in 2 or more contiguous leads * not associated with ST-elevation
46
What distinguishes acute or recent? * Anterior * Anteroseptal
ST elevation in **lead V1**
47
What distinguishes age acute or recent? * Lateral * Anterolateral
* Anterolateral * must show \> 1 mm ST-elevation in at least two contiguous leads * **V4-V6** * Lateral * must show \> 1 mm ST-elevation in at least two contiguous leads * **I, aVL**
48
Define Juvenile T-waves, normal variant
* TWI - localized to R precordial leads (V1 - V3) * shallow in depth * seen in younger, healthy individuals * typically females * Upright T waves in I, II, V5, V6
49
What is a major key to differentiating wide QRS tachycardias? * VT * SVT with aberrancy
Evaluate how tachycardia begins and ends * VT * starts - PVC * ends - gradual slowing of the rate and then termination * SVT with aberrancy * starts - PAC with long PR interval + narrow QRS complex * ends - narrow complexes at a similar rate and retrograde P waves
50
# Define: * Poor R-wave progression
* R wave in V3 \< 3 mm or * R/S transition zone in V5 or V6 * first precordial lead with R/S \> 1
51
What is the differential diagnosis: * Dominant R wave in V1
* Normal * RBBB * RVH * Dextrocardia * Limb lead reversal * Pacing * WPW * Duchenne muscular dystrophy * HCM * Posterior MI

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