Ekgcurriculum workbook pgy 1 2014 2015b by Emory University Department of Medicine

EKG Curriculum & Workbook PGY-1 2014-2015

A collaboration by Lorenzo Di Francesco, MD, Justin Cheeley, MD, Megan DeMoss, MD 1

Table of Contents 1. 2. 3. 4. 5. 6. 7.

EKG Curriculum PGY-1s EKG Pre-Assessment (PGY-1s) EKG Training, EKG resources & EKG PDF Workbook (PGY-1s) EKG Post-Assessment at the end of your Emory intern Cardiology month (PGY-1s) EKG Reading Method EKG vs. Clinical Diagnosis EKG Diagnostic Criteria a) Atrial fibrillation b) Atrial flutter c) Multifocal atrial tachycardia (“MAT or chaotic atrial tachycardia” or “chaotic atrial mechanism”) d) ST elevation myocardial injury pattern on a EKG and localize the area of injury/infarct • STEMI patterns are described below: Anteroseptal STEMI pattern Anterior STEMI pattern Anterolateral STEMI pattern Lateral STEMI pattern Posterior STEMI pattern Inferior STEMI pattern e) Prior myocardial infarction patterns on EKG (like “Q wave infarction” or “poor R wave progression from anterior wall MI”) • Left Ventricular Q-Wave Infarction Criteria Anteroseptal MI Anterior MI Anterolateral MI Extensive Anterior MI Lateral MI Posterior MI Inferior MI Inferolateral MI Inferoposterior MI Inferior MI with RV involvement f) Acute pericarditis g) First-Degree AV Block h) Second-Degree AV Block (Type 1 and Type 2) Second-Degree AVB Type 1 (Wenkebach) Second-Degree AVB Type II (Mobitz) i) Third-Degree AV Block j) Pre-excitation syndromes like Wolff-Parkinson White pattern 2

k) l) m) n) o) p) q)

Hypokalemia Hyperkalemia Acute right ventricular strain pattern Right bundle branch block Left bundle branch block Left ventricular Right ventricular hypertrophy

8. Practice EKGs by EKG Diagnosis (PGY-1s) 9. References a) PGY-1 Linked EKG Articles

1) EKG Curriculum PGY-1 Learning Goals & Objectives Medical Knowledge 1. All PGY-1s be able to systematically read an EKG identifying the rhythm, rate, identify abnormalities in the PR, QRS and QT intervals, QRS axis as well as additional abnormalities of the P wave, QRS complex, ST segment and T waves. 2. All PGY-1s be able to identify and differentiate between atrial fibrillation, atrial flutter and multifocal atrial tachycardia 3. All PGY-1s be able to identify ST elevation myocardial injury pattern on a EKG and localize the area of injury/infarct 4. All PGY-1s be able to identify myocardial ischemia (T wave inversion or ST depression in a coronary distribution) on a EKG 5. All PGY-1s be able to identify prior myocardial infarction (Q wave infarction, poor R wave progression from anterior wall MI) 6. All PGY-1s be able to identify the different stages of acute pericarditis on a EKG 7. All PGY-1s be able to identify primary AVB, both types of secondary AVB and third degree heart block on a EKG 8. All PGY-1s be able to identify pre-excitation syndromes including Wolff -Parkinson White on the EKG 9. All PGY-1s be able to identify changes of hypokalemia and hyperkalemia on a EKG 10. All PGY-1s be able to identify pattern of right ventricular strain on a EKG 11. All PGY-1s be able to identify a right or left bundle branch block on a EKG 12. All PGY-1s be able to identify left and right ventricular hypertrophy on a EKG 2) EKG Pre-Assessment and Introduction during new-intern Orientation a) Interns receive EKG Pre-Test • 10 EKG unknowns (1 hour 30 minutes) • Need to identify: Rhythm, Rate, Intervals (PR, QT) QRS duration/axis, Intervals, EKG diagnoses, as well as findings supporting their EKG diagnoses. • Graded by residency program (with pre-assessment scores maintained for each resident) b) Brief explanation of those 10 EKGs (by staff cardiologist; 30-45 min/session; 2 sessions that day--1 morning, 1 afternoon), and provide interns with resources (references) to learn EKGs (including the EKG Wave Maven site and EKG self-study Curriculum) 3) EKG Training, EKG resources & EKG PDF Workbook (PGY-1s) • Interns receive EKG didactic/interactive sessions during EUH, EUH-M Cardiology Rotations and utilize EKGs from both the workbook and current Cardiology patients • Interns have access to the EKG self-study workbook • Interns are encouraged to systematically study utilizing the EKG PDF Workbook. As well as EKG Wave Maven.

4) EKG Post-Assessment at the end of your Emory intern Cardiology month (PGY-1s) • • • • •

10 EKG unknowns (1 hour 30 minutes) Need to identify: Rhythm, Rate, Axis, Intervals, Diagnoses, Findings supporting Diagnoses From residency catalog of EKGs Graded by residency program (with pre-assessment scores maintained for each resident) All PGY-1s must receive at least a 70% on the EKG Post-Assessment test

5) EKG Reading Method 1. Rhythm (if not sinus what is it?) a. Sinus rhythm (normal P wave vector, every P followed by QRS and every QRS preceded by a P wave, HR between 60-100 and <10% variation between P-P intervals in the tracing) b. Sinus arrhythmia (normal P wave vector, every P followed by QRS and every QRS preceded by a P wave plus > 10% variation in P-P intervals in the tracing) c. Ectopic atrial rhythm (abnormal P wave vector, HR between 60-100 and frequently a shorter P-P interval is noted compared to patient’s baseline tracing) d. Sinus tachycardia (sinus rhythm + HR > 100) e. Sinus bradycardia (sinus rhythm + HR < 60) f. Second Degree AVB Type 1 (Wenkebach) g. Second Degree AVB Type II (Mobtiz) h. Third Degree AVB i. AV junctional rhythm (HR < 60) j. Accelerated AV junctional rhythm (HR > 60) k. Atrial fibrillation l. Atrial flutter m. Wandering atrial pacemaker (HR <100) n. Multifocal atrial tachycardia (HR >100) o. Ectopic atrial tachycardia (HR >100) p. AVNRT (AV node reentrant tachycardia) q. AVRT (AV reentrant tachycardia) r. Supraventricular tachycardia with aberrancy (RBBB or LBBB) s. Accelerated idioventricular rhythm t. Ventricular tachycardia u. Ventricular fibrillation 2. Rate a. Normal HR 60-100 b. Bradycardia < 60 c. Tachycardia > 100 3. Intervals (PR, QT) a. PR interval (0.12-0.2 seconds) b. QT interval (corrected QTc < 440 msec)

4. QRS duration & axis a. QRS Duration (0.06-0.10 seconds) b. QRS Horizontal plan i. -30 degrees to 105 degrees c. QRS Transition zone i. V2-V4 5. Other abnormalities to assess for…. a. P wave i. Duration 1. 0.08-0.11 seconds ii. Axis 1. 0-75 degrees iii. Morphology 1. Upright I, II; upright or inverted in aVF; inverted or biphasic in III, aVL, V1, V2; small notching may be present iv. Amplitude 1. Limb leads < 2.5 mm; V1; positive deflection < 1.5 mm and negative defection < 1 mm b. Look for atrial chamber enlargement i. RAA ii. LAA c. Look for ventricular chamber enlargement i. RVH (see criteria section below) ii. LVH (see criteria section below) d. PR segment (identify location i.e. aVR) i. Elevation ii. Depression e. ST segment (identify location i.e. V1-V3) i. Morphology 1. Usually isoelectric; may vary 0.5 mm below to 1 mm above baseline in limb leads 2. Elevation (“injury pattern”) 3. Depression (“subendocardial ischemia”) f. T waves (identify location i.e. II, III, aVF) i. Morphology 1. Upright in I, II, V3-V6; inverted in aVR, V1 may be upright, flat or biphasic in III, aVL, aVF, V1, V2; T wave inversion may be present in V1-V3 in healthy young adults (juvenile T waves) ii. Amplitude 1. < 6 mm in limb, < 10 mm in precordial iii. Always describe T waves if abnormal 1. Inverted 2. Peaked 3. Flattened g. Q waves (identify location i.e. V4-V6) h. U waves (identify location i.e. V1-V4) 6

i. Morphology 1. Upright in all leads except aVR ii. Amplitude 1. 5-25% of the height of the T wave (usually < 1.5mm) iii. Always describe U waves (identify location i.e. V1-V2) if 1. Prominent > 1.5 mm 2. Inverted (except in aVR) i. Miscellanous findings i. PAC (premature atrial contraction) ii. PVC (premature ventricular contraction) iii. Fusion beats iv. Capture beats v. Flutter wave vi. Delta wave vii. Osborn wave viii. Brugada wave ix. Epsilon wave 6) EKG vs. Clinical Diagnosis j. EKG Diagnosis i. If only have EKG would make your best fit “EKG diagnosis.” k. Clinical Diagnosis i. Using clinical information from the H/P and EKG should allow you to make an appropriate “Clinical Diagnosis.” 7) EKG Diagnostic Criteria PGY-1s a) Atrial fibrillation 1. P waves are absent. The atrial activity is represented by fibrillatory (f) waves of varying amplitude, duration and morphology that cause random oscillation of the baseline 2. The ventricular rhythm, in the absence of AV block is irregularly irregular b) Atrial flutter 1. The atrial deflections consist of rapid regular undulations (the F waves) that give rise to a sawtooth appearance in some leads 2. The atrial rate is usually between 250-350 beats/min 3. The rate and regularity of the ventricular complexes are variable and depend on the AV conduction sequence 4. The QRS complex may be normal or abnormal as a result of preexisting intraventricular conduction defect or aberrant ventricular conduction. c) Multifocal atrial tachycardia (“MAT or chaotic atrial tachycardia” or “chaotic atrial mechanism”) 1. P waves of varying morphology from at least three different foci demonstrated in the same lead 2. The absence of one dominant atrial pacemaker (in distinction to normal sinus rhythm with frequent multifocal premature atrial beats) 3. Variable PP, RR and PR intervals 7

4. Atrial rate > 100 beats/min d) ST elevation myocardial injury pattern on a EKG and localize the area of injury/infarct • Acute ST-elevation myocardial infarction (STEMI) is identified by the following evolutionary changes: 1. Hyperacute T waves, which are tall, peaked, and symmetric. 2. Elevation of the ST segment in contiguous leads, depending upon the location of the MI. The ST elevation is at first concave and then becomes convex, merging with the T wave (current of injury) document by serial EKGs 3. Development of Q waves and T wave inversions as the ST segments return to baseline. 4. The electrocardiographic changes that occur in patients who sustain a non-ST elevation MI (NSTEMI) are different. T wave flattening or inversion typically precedes ST segment depression. Q waves are typically absent but can occur, and the duration of the ST and T wave changes is variable. • STEMI patterns are described below: Anteroseptal STEMI pattern 1. ST segment elevation > 1 mm in leads V1, V2 and sometimes V3, V4 Anterior STEMI pattern 1. ST segment elevation > 1 mm in leads V1, V2, V3 and sometime V4 Anterolateral STEMI pattern 1. ST segment elevation > 1 mm in leads V4, V5, V6 sometimes in I and aVL Lateral STEMI pattern 1. ST segment elevation > 1 mm in leads I, aVL Posterior STEMI pattern 1. ST segment depression > 1 mm in leads V1-V3 Inferior STEMI pattern 1. ST segment elevation > 1 mm in leads II, III, aVF i. If ST elevation in V5, V6Inferolateral STEMI pattern ii. If ST depression in V1-V3Inferoposterior STEMI pattern iii. If ST elevation in V1 or V2 or VR4Inferior STEMI with RV involvement pattern e) Prior myocardial infarction patterns on EKG (like “Q wave infarction” or “poor R wave progression from anterior wall MI”) • A chronic MI, or infarction of indeterminate age, is characterized by initial Q waves that are deep (>1 mm) and broad (> 0.03 to 0.04 seconds). These Q waves may be associated with an inverted T wave. The location of these changes is dependent upon the location of the MI. • Left Ventricular Q-Wave Infarction Criteria Anteroseptal MI 1. QS deflections in leads V1, V2, V3 and sometimes V4 Anterior MI 1. rS deflection in V1 followed by Q waves in one or more leads V2-V4 Anterolateral MI 1. Abnormal Q waves in leads V4 or V5 thru V6, I, and aVL Extensive Anterior MI 8

1. QS deflections in nearly all precordial leads (V1-V6) with or without Q waves in leads I and aVL Lateral MI 1. Q waves in leads I and aVL Posterior MI 1. Initial R wave in V1 and V2 (duration 0.04 or longer) with R/S ratio equal to or greater than 1 (patient over the age 30 without h/o RVH) Inferior MI 1. Q waves in II, III, aVF (Q wave in aVF is abnormal) Inferolateral MI 1. Q waves in II, III, aVF plus Q waves in V5 and V6 Inferoposterior MI 1. Q waves in II, III, aVF plus tall R wave in V1 with duration 0.04 or longer and R/S ratio equal to or greater than 1 Inferior MI with RV involvement 1. Because of lack of specific QRS changes and the very transient nature of the ST segment changes old right ventricular infarcts cannot be diagnosed by EKG f) Acute pericarditis 1. P wave is normal 2. PR segment may be depressed (except in lead aVR where it might be elevated) 3. Diffuse ST segment elevation most leads (mostly V5, V6, I, II) Evolution of the EKG changes more helpful in diagnosis • Stage 1 Diffuse ST segment elevation • Stage 2 ST junction returns to baseline, T wave amplitude decreases • Stage 3 Diffuse T wave inversion • Stage 4 EKG changes resolve back to baseline 4. Optional but not required EKG findings • Low voltage of the QRS (if associated with significant pericardial effusion) • Electrical alternans (“P, QRS or T wave alternans” implies presence of pericardial effusion but only “total electrical alternans” involving P, QRS and T waves that is diagnostic of cardiac tamponade) g) First-Degree AV Block 1. PR interval is greater than 0.20 seconds (“> one large box) 2. Each P wave is followed by QRS complex h) Second-Degree AV Block (Type 1 and Type 2) Second-Degree AVB Type 1 (Wenkebach) 1. Progressive lengthening of the PR interval until a P wave is blocked 2. Progressive shortening of the RR interval until a P wave is blocked 3. The RR interval containing the blocked P wave is shorter than the sum of the 2 PP intervals Second-Degree AVB Type II (Mobitz) 1. Intermittent blocked P waves 2. In the conducted beats, the PR intervals remain constant

i) Third-Degree AV Block

1. There is an independence of the atrial and ventricular activities 2. The atrial rate is faster than the ventricular rate. The atrial rhythm may be sinus or ectopic in origin 3. The ventricular rhythm is maintained by either a junctional or an idioventricular pacemaker. Pre-excitation syndromes like Wolff-Parkinson White pattern 1. PR interval of less than 0.12 seconds with a normal P wave 2. Abnormally wide QRS complex with a duration of 0.11 seconds or greater • Type A delta wave and QRS upright in all precordial leads (resembles incomplete RBBB) • Type B delta wave and QRS negative in V1, V2 but upright in left precordial leads (resembles incomplete LBBB) • Type C (rare) delta wave is positive in V1-V5, negative in V5, V6 3. The presence of an initial slurring of the QRS complex (“delta wave”) 4. Secondary ST-segment and T wave changes Hypokalemia 1. Prominent U waves 2. ST segment depression 3. Decreased T wave amplitude Hyperkalemia (presence of findings depends on acuity of elevation and absolute K+ level, finding can be combination of those listed below) K+ 5.6-6.5 1. Tall, narrow and peaked T waves 2. QT interval shortening 3. Reversible LAFB or LPFB K+6.5-7.5 1. First degree AVB 2. Flattening and widening of P wave 3. ST segment depression 4. QRS widening K+>7.5 1. Decrease amplitude of P waves or absent P waves 2. Intermittent or marked AVB (secondary or third degree) 3. ST-segment changes simulating current of injury (significant ST elevation) 4. LBBB or RBBB, or markedly widened and diffuse intraventricular conduction delay leading to “sine wave pattern” (can lead to VT or VF pattern) Acute right ventricular strain pattern (potentially due to acute pulmonary embolism) Findings that might be considered typical of acute pulmonary embolism 1. S1Q3 or S1Q3T3 pattern or 2. Rightward shift of QRS axis or 3. Transient incomplete or complete RBBB or 4. Acute T-wave inversion in right precordial leads (V1, V2, V3) 10

n) Right bundle branch block 1. QRS duration to 0.12 seconds or greater 2. A secondary R wave (R’) in the right precordial leads, with the R’ greater than the initial R wave (i.e. rsR’ or rSR’) 3. A delay in the onset of the intrinsicoid deflection in the right precordial leads greater than 0.05 seconds 4. A wide S wave in leads I, V5 and V6 o) Left bundle branch block 1. QRS duration of 0.12 seconds or greater 2. Presence of a broad monophasic R wave in leads I, V5 and V6 which is usually notched or slurred 3. Absence of Q waves in leads I, V5 and V6 4. Delay of onset of the intrinsicoid deflection (the R peak time) in leads V5 an V6 5. Displacement of the ST segment and T wave in a direction opposite to the major deflection of the QRS complex 6. Other findings not necessary • Poor R wave progression in right and mid precordial leads • RS complex in the left precordial leads • Abnormal left axis deviation • QS deflection in the inferior leads p) Left ventricular hypertrophy (multiple criteria with good specificity but poor sensitivity) Sokolow-Lyon Criteria (sens 11% spec 100%) 1. S V1 + R V5 or V6 > 35mm or 2. R aVL > 11mm Cornell Criteria (sens 36% spec 96%) 1. male R aVL + S V3 >28mm or 2. female R aVL + S V3 >20mm Estes-Romhilt Criteria (sens 53% spec 97%) 5 points or more definite, 4 probable 1. Voltage R or S limb >20mm 3pts (any one) S V1-2 >30mm R V5-6 >30mm 2. “ST-T strain” (ST dep/T wave inversion V5, V6, I, aVL) not on digoxin 3pts taking digoxin 1pt 3. LAE 3pts 4. LAD 2pts 5. QRS dur >=0.09 sec 1pt 6. Intrinsicoid deflection V5-6 ->=0.05 sec 1pt q) Right ventricular hypertrophy Presence of one or more in setting of QRS duration < 0.12 1. RAD > 110 degrees 2. R/S ratio in V1 > 1 3. R wave in V1 > 7mm 4. S wave in V1 < 2mm 11

5. qR pattern in V1 6. rSRâ&#x20AC;&#x2122; in Vq with Râ&#x20AC;&#x2122; > 10 mm additional supporting findings but not necessary 7. ST depression and T wave inversion in right precordial leads (V1-V3) 8) Practice EKGs (PGY-1s) (Representatives of each of the below are available for your practice) a) Atrial fibrillation b) Atrial flutter c) Multifocal atrial tachycardia d) Acute STEMI e) old MI f) Acute pericarditis g) Primary AV Block h) Secondary AV Block i) Third degree AV Block j) Right bundle branch block k) Left bundle branch block l) Pre-excitation syndromes like Wolf Parkinson White pattern m) Hypokalemia n) Hyperkalemia o) Acute right ventricular strain p) Left ventricular hypertrophy q) Right ventricular hypertrophy

9) References a) PGY-1 Articles Electrocardiography in Clinical Practice: Adult and Pediatric. Te-Chuan Chou, MD. 4th edition. W.B. Saunders. 1996. Use of the Electrocardiogram in Acute Myocardial Infarction. NEJM. 2003;348:933-940. Thoughts About the Abnormalities in the Electrocardiogram of Patients with Acute Myocardial Infarction with Emphasis on a More Accurate Method of Interpreting S-T Segment Displacement: Part I. Hurst, J. Clin. Cardiol. 2007;30:381-390. Thoughts About the Abnormalities in the Electrocardiogram of Patients with Acute Myocardial Infarction with Emphasis on a More Accurate Method of Interpreting S-T Segment Displacement: Part II. Hurst, J. Clin. Cardiol. 2007;30:443-449.

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