Important EKG’s

for the Geriatrician

Ned H. Gutman

8 September, 2011

Normal EKG

• Sinus rhythm-

– P waves upright inferior leads

• Normal axis/intervals/voltage

– Negative in aVR

• No pathologic Q waves

• Normal R wave transition

• Normal ST segments/T waves

LVH

• Important to recognize

• Prognostic implications

• “end organ” involvement

• Many criteria

S (V1 or V2) + R (V5 or V6) > 35 mm

R (V5 or V6) > 26 mm

EKG #2 49 yo asymptomatic man, no prev eval,

no meds, exercises 6+ days/wk

a) Normal EKG

b) LVH due to Aortic stenosis with

bicuspid aortic valve

c) LVH due to steroid use

d) Primary hypertrophic cardiomyopathy

e) LVH due to rheumatic mitral stenosis

EKG standard

• Speed 25 mm/s

• Standard box height 10 mm

• sharp corners

What do you call 2 orthopedists

reading an EKG?

• A double blind study

LBBB EKG #3a, 67 yo woman with class III

CHF, EF 20%, no CAD

• QRS >120 ms

• QS in V1 (sometimes small r wave)

• Monophasic R in V6

• If associated with LAD (>-30 deg),

higher incidence of CAD or myopathy

EKG #3b

• S/p BiV ICD

• Note small pacing spikes in rhythm strip

• Paced beats have a much narrower

complex, usually have shorter PR to

ensure mostly paced

• EF improved 45%

Abnormal Anterior T waves

• Strained T waves usually are directed opposite to the major QRS deflection, eg LVH, extreme T abn seen in HCM

• In BBB, the T wave is normally directed opposite to the terminal portion of the QRS

• Primary T abnormalities- may be seen in ischemia- aka Wellen’s sign

EKG #4

• 68 yo woman with new left CP, assoc

with SOB

• H/O breast ca, s/p left XRT, receiving

Hercepten

• Quit cigs 2 yr ago, M/Sis/Bro +CAD

• +HTN and Chol

• Cath-70% LM, 80% prox LAD ulcer

EKG #5

• 42 yo woman, s/p renal transplant,

treated HTN, new exertional chest and

arm tightness, marked LDL elev not

prev known (due to anti-rejection meds)

• Terminal T inv in V3 and V4

• 85% proximal LAD stenosis

EKG #6

• 58 yo man, atypical CP, hyperlipidemia

on statin

• Stress ECHO demonstrated apical

akinesis

• Cardiac cath- non critical LAD disease

• Small apical aneurysm

• Hypertrophic cardiomyopathy

Worcester

Gloucester

• Syncope

• loss of one or more sounds from the

interior of a word

Heart Block

Syncope due to transient heart block is

rarely seen with a normal baseline EKG

• Exercise induce heart block is very

specific for infra-nodal block

EKG 7

83 yo man • 1-2 months progressive exercise intol/DOE,

esp climbing stairs.

• No CP/palp/syncope

• CAD, s/p circ PCI 1999, nl nuc 2009

• CRI, creat 2’s, Diabetes

• Metoprolol, simvastatin, glyburide, asa

• HR in office 60’s, dropped to 30’s with activity

Which of the following is least

associated with the conduction

disease seen in this patient?

a) Age

b) Use of beta blocker

c) Diabetes

d) Renal insufficiency

e) H/O CAD

EKG 8

71 yo woman • Exertional epigastric discomfort & dyspnea

while walking in Newport. No syncope.

• Old RBBB and LAHB- unchanged

• ECHO & Nuc stress normal 3 mo ago

• BRCA+, s/p hysty & bilat mastect, no XRT

• In ER noted to have transient 2:1 conduction,

this was easily reproduced with walking

• Pacemaker successfully implanted

MRI compatible pacemakers

• Estimated that >50% of pts who receive pacemakers will have some future need for an MRI

• Previous pacemaker patients could not get MRI-wire tips get hot, mess up generator electronic cicuitry

• Currently 1 company (Medtronic, 2/1/11) has an approved MRI compatible device

• In these patients, only MRI’s above neck or below waist are allowed

Atrial Fib/flutter

EKG 9/10 • Afib-irreg, sometimes coarse fib waves, best

seen in V1

• Aflutter- flutter wave rate 250-300, often some

periods of regularity at intervals related to

flutter waves (eg150, 100, 75), Best seen in

inferior leads (2, 3, F)

• Does it matter?- both often warrant anticoag,

flutter may be more challenging to rate

control, flutter much easier to ablate than fib

EKG 11

• Regularization of Atrial Fib

• Progressive conduction disease

• Too much AV slowing meds, may see

junctional escape

– Dig, B-b, Ca-ch-b

– I hate digoxin in old old pts and those with even

mild renal insuf, therapeutic window is too narrow

Which is NOT a sign/symptom

of digoxin toxicity?

a) Nausea

b) Altered vision

c) Bradycardia-afib regularization

d) Ventricular ectopy, salvos of VT

e) ST segment slurring

EKG 12

Final Exam

a) Atrial Fib

b) Atrial Flutter

c) Paroxysmal atrial tachycardia with

block

d) Something else