ECG Cases

This trace show moment idioventricular rhythm degenerate into ventricular fibrillation and then ultimately degenerating into ventricular asystole.  Ventricular arrhythmias   are the most frequent cause of sudden cardiac death.

This ECG registered in patient without pulse shows pulseless electrical activity. Pulseless electrical activity (Electromechanical dissociation) is one of three types of cardiac arrest together with ventricular fibrillation and asystoly. Normally electrical activity produces mechanical activity. In electromechanical dissociation we have electrical activity in ECG but no pulse is present. This pathology should be treated with cardiopulmonary resuscitation. In ECG, electromechanical dissociation may have different appearance (with narrow or wide QRS complexes).

A)     Polymorphic ventricular tachycardia. We can see wide complex tachycardia with QRS complexes that have different amplitude, axis and continuously evolving morphology. B)      Atrial Fibrilation. Irregularly irregular rhythm with no P wave. C)     Atrial flutter with 2:1 conduction D)      Low atrial rhythm. Inverted P wave before each QRS complex and constant PR interval.

This ECG shows: a) RBBB b) LBBB c) IVCD This ECG present typical changes for RBBB. The RBBB criteria fulfilled in this case are: -           Supraventricular rhythm. -           Wide QRS complex (>120 ms) with rsR’ morphology. -           Slurred S wave in V6. -           T wave discordance in precordial leads.   The most common cause of RBBB are: ASD, COPD, right ventricular hypertrophy, pulmonary thromboemboli, ischaemic heart disease, hypertension, cardiomyopathy.

What is your diagnosis?               a)         STEMI inferioris + second degree AVB              b)       Normal sinus rhythm + STEMI inferioris              c)       Normal ECG              d)    STEMI inferioris + NSTEMI parietis lateralis

The most probable diagnosis on those rhythm strips are as following: a) Sinus rhythm with wide QRS complexes. b) Atrial fibrilation with wide QRS complexes. c) PSVT (paroxysmal supraventricular tachycardia). d) WCT (most probable Ventricular tachycardia). e) Escape junctional rhythm

Patient with chest pain. What is your diagnosis? a)       STEMI infero-posterioris. Mobitz I b)       STEMI infero-lateralis. Mobitz I c)        STEMI inferioris. Mobitz II d)       STEMI inferioris. Total AVB e)       STEMI inferioris. NSTEMI anterioris. Second degree AVB This ECG shows ST elevation in inferior leads that’s mean STEMI inferior is present.   Posterior STEMI is suggested by horizontal ST depressions, upright T Wave and tall R wave in right precordial leads. PR interval is not constant. We can see progressive prolongation of this interval culminating with non conducted P wave, typical for second degree AVB, Mobitz I, that appear in P:QRS group with ratio 3:2 or 4:3. Incomplete LBBB is present too. Final diagnosis: a)  STEMI infero-posterioris. Mobitz I

The name of QRS complexes is as following:  1.Rs, 2.qRs, 3.QS, 4.RS, 5.QR, 6.rsR', 7.R, 8.rS, 9.RR'.

This ECG shows: a) Sinus rhythm with LBBB b) Atrial fibrillation with LBBB c) Ventricular tachycardia with LBBB morphology?

What is your diagnosis and the best treatment? In this ECG Case we can't identify any P waves, QRS complexes or T waves. All what we can see is chaotic irregular ventricular deflections of varying amplitude and frequency >400/min. This findings are features of Ventricular fibrillation • Ventricu lar fibrillation can be coarse and fine. Coarse ventricular fibrillation occurs earlier after the onset of cardiac arrest and has high amplitude fibrillatory waves. In opposite, fine ventricular fibrillation occurs more later, is less organized with lower amplitude fibrilatory waves. • Coarse ventricular fibrillation frequently looks like TDP or Non-TDP polimorphyc VT. • Previus ECG of this patient did not have a long QT. This fact is against TDP.  In conclusion patient was hemodynamically unstable so in this moment it is not important to differentiate Coarse VFib from TDP. Gave unsynchronized cardioversion (Defibrillation) to the patient.

25 years old male with palpitations. What is your plan for further management of this case. Brugada syndrome is rare cardiac disease with genetic substrate. ECG featuring for Brugada Syndrome is RBBB (or incomplete RBBB) with ST elevation in right precordial leads. Diagnosis is based on this specific ECG pattern, observed either spontaneously or during provocation tests such is Ajmalin test. Genetic test and electrophysiological studies can be uses too, to make the diagnosis of this disease and to assess the risk of sudden death from cardiac arrhythmias. Brugada represent high risk for sudden cardiac death.

Patient with dyspnea.? QRS complexes are narrow with low amplitude. Maximal amplitude of QRS complex in the limb leads is 2mm and in precordial leads 8mm. Low voltage ECG is confirmed if QRS amplitude in limp leads is less then 5mm and in precordial leads less then 10mm. The most common cause of microvoltage are: Pericardial effusion, COOD, obesity, hypothyroism, restrictive cardiomyopathy. Next significant findings is irregularly irregular rhythm without P wave. This is enough to diagnose atrial fibrillation with ventricular rate ~90/min. Final diagnosis: Microvoltage. Atrial fibrilation with controlled ventricular rate.

A) Sinus tachycardia is sinus rhythm with heart rate over 100/min. This rhythm is regular with normal appearance P wave and normal duration PR intervals. QRS complexes can be narrow or wide. B) Sinus bradycardia is sinus rhythm with heart rate bellow 60/min. This rhythm is regular with normal appearance P wave and normal duration PR intervals. QRS complexes can be narrow or wide. C) Sinus arrhythmia is sinus rhythm with variation of P-P (R-R) intervals at least 120ms. P wave has normal appearance and normal PR intervals. QRS complexes can be narrow or wide.

Choice two right answers about this ECG? Inferior STEMI+ Lateral NSTEMI  Inferior STEMI LCX is Culprit artery  RCA is Culprit artery  LAD is Culprit artery.    ST elevation in leads II, III and aVF with Q waves in II, aVF plus reciprocal ST depressions in aVL diagnose STEMI parietis inferioris. ST depression in lateral leads doesn’t present NSTEMI. If ST elevation in lead III > lead II than RCA is culprit artery. Circumflex occlusion in inferior STEMI is suggested if ST elevation in II = ST elevation in III with absence of reciprocal ST depression in lead I.

Name this Blocks A. First degree AVB is present in this rhythm strip. Every P wave is conducted, but with prolonged PR interval (~320ms). B. Second degree AVB type 1 (Mobitz I) is present in this rhythm strip. We can see progressive prolongation of the PR interval culminating in a non-conducted P wave (3d and 7d P wave are non-conducted). C. Second degree AVB type 2:1 is present in this rhythm strip. We can see that there are 2P waves for every QRS complex. We don’t have two P wave conducted in a row so can’t conclude if PR interval is prolonged (Mobitz I) or constant (Mobitz II). D. High degree AVB (3:1) is present in this rhythm strip. We can see that just every 3d P wave is conducted (with constant PR interval) and two out of every three P wave are blocked. E. High degree AVB (4:1) is present in this rhythm strip. We can see that just every 4d P wave is conducted (with constant PR interval) and three out of every four wave are blocked. F. Third degree AVB is present i

1. The first ECG finding of this ECG Case is non standard voltage calibration . Instead of 10mm/1mv, voltage calibration is done 5mm/1mv. Half standard calibration was used to prevent superposition of waveforms.             At the beginning of the ECG recording, the ECG machine automatically performs a calibration while recording a rectangular shape signal with different amplitude. Fig.1.The calibration signal (marked with red) has 5mm vertically. This show presence of half standard calibration (5mm/1mv), instead of 10mm/mV. 2. Basic normocardic sinus rhythm is interfered from a Ventricular Extrasystole (QRS nr. 4). This complex fulfills all criteria for Ventricular Extrasystole: QRS is wider than 0.12 s, is premature, followed by a compensatory pause and discordant ST.               From QTS complex nr.7, begins a regular uniform wide complex tachycardia and continues until end of rhythm strips (QRS nr.24). Rhyt

  20 years old male patient with episodes of dizziness. In this patient with sinus rhythm, clearly there are some blocks on this ECG.              1.        Right bundle branch block (RBBB), as was marked with red color.                  - QRS duration >120 ms                  - QRS with morphology rsR’ in lead V1 and slurred S wave in V6.                   -Discordant T wave in V1.         2.      Left anterior fascicular block (LAFB), as was marked with blue color.                   - Left axis deviation, >-30                   - qR in leads I and aVL and rS complexes in leads II and III                3.     First-degree atrioventricular block, as was marked with red color.                    - PR interval duration >200 ms. The combination of RBBB, LAFB and First degree AVB is called Trifascicular block, which indicate presence of severe disease of heart electrical conduction system. Besides trifascicular block, important fin

74 years old patient with palpitations and history of myocardial infarction In this ECG is present  wide complex tachycardia  (QRS duration >120ms) with heart rate ~180/min. The main differential diagnosis of Wide Complex Tachycardias are:                     a)        Ventricular tachycardia                         b)        Supraventricular tachycardia with RBBB or LBBB                    c)        Supraventricular tachycardia with pre excitation. In this case, ECG findings strongly support  Atrial fibrillation with LBBB  (Supraventricular tachycardia with LBBB) before VT or pre excitation. First of all the rhythm is irregularly irregular and no supraventricular activity is present. This is very typical for atrial fibrillation. QRS complexes have typical morphology for  LBBB  (QS in V1 and notched R wave in lead V6). There is no electrocardiographic features for ventricular tachycardia present. No  AV dissociation, no positive or negative concordan

This ECG was registered in 75 years old patient with abdominal pain Which abnormality can you spot on this ECG? a. STEMI b. NSTEMI c. First degree AVB d. Second degree AVB e. Third Degree AVB f. Acute epricarditis g. BER

Patient with history of cardiac disease, hemodynamically unstable. What is your diagnosis?

In a rhythm strip A , presents Pulmonary P wave that suggests right atrial enlargement. P wave with duration less than 120ms and amplitude more than 2.5mm.  In a rhythm strip B , presents Mitrale P wave that suggests left atrial enlargement. P wave with duration more than 120 ms and amplitude less than 2.5mm.  In a rhythm strip C , presents Biphasic P wave with terminal negative portion more than 40 ms and more than 1mm deep which suggests left atrial enlargement.  In a rhythm strip D, presents Inverted P wave preceding each QRS complex with normal PR interval that suggest low atrial rhythm.  In a rhythm strip E , presents Normal P wave that suggests normal sinus rhythm.

25 years old male with persistent burning chest pain since 5 hour. No risk factor for heart disease. Troponins negative. What is your diagnosis and what to do further? (Pacienti mashkull 25 vjeq me dhimbje djegëse të gjoksit qe 5 orë. Pa faktor risku për sëmundje kardiake. Troponinat negative. Cila është diagnoza juaj dhe cka do bënit tutje?)