CARDIOLOGY 1

Dr. Amro Adas

Internal Medicine Specialist
 ECG
 ECG is the abbreviated term for an

electrocardiogram. It is used to record the

electrical activity of the heart from
different angles to both identify and locate
pathology. Electrodes are placed on
different parts of a patient’s limbs and
chest to record the electrical activity.
PARTS OF THE ECG
 P waves

- P waves represent atrial depolarisation.

- In healthy individuals, there should be a P wave preceding
each QRS complex.

 PR interval

- The PR interval begins at the start of the P wave and ends at the
beginning of the Q wave.
- It represents the time for electrical activity to move between the atria
and the ventricles.

 QRS complex

- The QRS complex represents the depolarisation of the ventricles.

- It appears as three closely related waves on the ECG (the Q, R and S
wave).
 ST segment

- The ST segment starts at the end of the S wave and ends at the beginning of the T
wave.
- The ST segment is an isoelectric line representing the
time between depolarisation and repolarisation of the ventricles (i.e. ventricular
contraction).

 T wave

- The T wave represents ventricular repolarisation.

- It appears as a small wave after the QRS complex.

 RR interval

- The RR interval begins at the peak of one R wave and ends at the peak of the next R
wave.
- It represents the time between two QRS complexes.

 QT interval

- The QT interval begins at the start of the QRS complex and finishes at the end of the T
wave.
- It represents the time taken for the ventricles to depolarise and then repolarise.
HOW TO READ ECG
PAPER
LOCALIZING PATHOLOGY ON THE ECG
HOW TO READ ECG
 Confirm details
 Before beginning ECG interpretation, you should check the following
details:
• Confirm the name and date of birth of the patient matches the details on
the ECG.
• Check the date and time that the ECG was performed.
• Check the calibration of the ECG (usually 25mm/s and 10mm/1mV).
 HEART RHYTHM
 A patient’s heart rhythm

can be regular or irregular.

 Irregular rhythms can be

either:
• Regularly irregular

(i.e. a recurrent pattern of

irregularity)
• Irregularly irregular

(i.e. completely
disorganised) Atrial Fibrillation
 HEART RATE
 If a patient has a regular

heart rhythm:

• 300/ Number of large

squares present within one

R-R interval
 If a patient’s heart rhythm is irregular:
 Count the number of complexes on the rhythm strip (each rhythm strip is
typically 10 seconds long).
• Multiply the number of complexes by 6 (giving you the average number of
complexes in 1 minute).
CARDIAC AXIS
 The next step is to look at the P waves and answer the following questions:

1. Are P waves present?

2. If so, is each P wave followed by a QRS complex?
3. Do the P waves look normal? – check duration, direction and shape
4. If P waves are absent, is there any atrial activity?

• Sawtooth baseline → flutter waves

• Chaotic baseline → fibrillation waves
• Flat line → no atrial activity at all
 The PR interval should be between 120-200 ms (3-5 small squares).

 A prolonged PR interval suggests the presence of atrioventricular delay (AV

block)
 Second-degree AV block (type 1) is also known as Mobitz type 1 AV
block or Wenckebach phenomenon.
 Typical ECG findings in Mobitz type 1 AV block include progressive
prolongation of the PR interval until eventually the atrial impulse is not
conducted and the QRS complex is dropped.
 Typical ECG findings in Mobitz type 2 AV block include a consistent PR
interval duration with intermittently dropped QRS complexes due to
a failure of conduction.
 Third-degree (complete) AV block occurs when there is no electrical
communication between the atria and ventricles due to a complete
failure of conduction.

 Typical ECG findings include the presence of P waves and QRS

complexes that have no association with each other, due to the atria
and ventricles functioning independently.
QRS COMPLEX
 When assessing a QRS complex, you need to pay attention to the
following characteristics:
- Width
- Height
- Morphology
 The width can be described as NARROW (< 0.12 seconds) or BROAD (>
0.12 seconds):

- A narrow QRS complex occurs when the impulse is conducted above the
aV nde (in the atrium)
- A broad QRS complex occurs if there is an
abnormal depolarisation sequence starts
in the ventricules. bundle branch block
• LBBB: deep S wave in V1 which may be notched (“W”) and broad “M”
shaped R wave in V6 WiLLiaM
• RBBB: RSR’ pattern in V1 (“M”) and broad S wave in V6 (“W”) MaRRoW
 Delta wave in QRS
 The mythical ‘delta wave‘ indicates that the ventricles are being activated
earlier than normal from a point distant from the AV node.
 The early activation then

spreads slowly across the

myocardium, causing the QRS
complex’s slurred upstroke.
 HEIGHT OF QRS
 Height can be described as either SMALL or

TALL:

• Small complexes are defined as < 5mm in the

limb leads or < 10 mm in the chest leads.

(pericardial effusion or amyloidosis).
• Tall complexes imply ventricular hypertrophy

(although can be due to body habitus e.g. tall slim

people).
ST SEGMENT
 The ST segment is the part of the ECG

between the end of the S wave and the

start of the T wave.

 In a healthy individual, it should be an

isoelectric line (neither elevated nor

depressed).
 ST-elevation is significant when it is

greater than 1 mm (1 small square) in 2 or

more contiguous limb leads or >2mm in 2
or more chest leads.

 It is most commonly caused by acute

full-thickness myocardial infarction.

St elevation in all leads suggestive of

Pericarditis or myocarditis.
 ST depression ≥ 0.5 mm in ≥ 2 contiguous
leads indicates myocardial ischemia.
 Tall T waves

- T waves are considered tall if

they are:
• > 5mm in the limb leads AND
• > 10mm in the chest leads

(the same criteria as ‘small’ QRS

complexes)

 Tall T waves can be associated

with:
• Hyperkalaemia (“tall tented T waves”)
• Hyperacute STEMI
SINUS BRADYCARDIA AND AV BLOCK
 Sinus bradycardia is defined as HR < 60 on ECG with normal PR interval

which is 120-200 msec (3-5 small squares).

HEART BLOCK
 The first question is the rhythm regular or irregular

 If regular (first degree AV block or 3rd degree AV block).

 In first degree AV block, PR interval prolonged but and constant

 In third degree AV block, PR interval is not constant, (complete dissociation

between P and QRS).
 IF rhythm is not regular, then it is second degree AV block (either Mobitz 1
or Mobitz 2).

 If PR interval is not constant and there is progressive prolongation then it is

second degree Mobitz 1

 If PR interval is constant with drop of QRS then it is second degree Mobitz

2.
AV BLOCK
 Atrioventricular (AV) block (often referred to as “heart block”) involves the
partial or complete interruption of impulse transmission from the atria to
the ventricles.
 This interruption of impulse transmission results in characteristic ECG
findings that differ depending on the subtype of AV block.
 The most common cause of AV block is idiopathic fibrosis and sclerosis of the
conduction system.
 Any patient presenting with AV block requires investigation to identify
underlying causes:
- ECG: to help determine the subtype of AV block
- Laboratory investigations (e.g. FBC, U&Es, TSH, troponin): to rule out
underlying causes
- Echocardiogram: to rule out structural heart disease
 Causes of first-degree AV block include:
• Enhanced vagal tone: often seen in athletes (non-pathological)
• Post myocardial infarction
• Lyme disease
• Systemic lupus erythematosus
• Congenital
• Myocarditis
• Electrolyte derangements
• Drugs: particularly AV blocking drugs such as beta-blockers,

rate-limiting calcium-channel blockers, digoxin and

magnesium1
• Thyroid dysfunction
 Causes of second-degree AV block (type 1) include:

• Increased vagal tone: often seen in athletes (non-pathological)

• Drugs: beta-blockers, calcium channel blockers, digoxin, amiodarone
• Inferior myocardial infarction
• Myocarditis
• Cardiac surgery (mitral valve repair, Tetralogy of Fallot repair)
 Causes of second-degree AV block (type 2) include:
• Myocardial infarction
• Idiopathic fibrosis of the conducting system (Lenegre’s or Lev’s disease)
• Cardiac surgery (especially surgery occurring close to the septum such as
mitral valve repair)
• Inflammatory conditions (rheumatic fever, myocarditis, Lyme disease)
• Autoimmune (SLE, systemic sclerosis)
• Infiltrative myocardial disease (amyloidosis, haemochromatosis, sarcoidosis)
• Hyperkalaemia

• Drugs (e.g. beta-blockers, calcium channel blockers, digoxin, amiodarone)

• Thyroid dysfunction
 Causes of third-degree (complete) AV block include:
• Congenital: structural heart disease (e.g transposition of the great vessels),
autoimmune (e.g maternal SLE)
• Idiopathic fibrosis: Lev’s disease (fibrosis of the distal His-Purkinje system in the
elderly) and Lenegre’s disease (fibrosis of the proximal His-Purkinje system in
younger individuals)
• Ischaemic heart disease: myocardial infarction, ischaemic cardiomyopathy
• Non-ischaemic heart disease: calcific aortic stenosis, idiopathic dilated
cardiomyopathy, infiltrative disease (e.g. sarcoidosis, amyloidosis)
• Iatrogenic: post-ablative therapies and pacemaker implantation, post-cardiac
surgery
• Drug-related: digoxin, beta-blockers, calcium channel blockers, amiodarone
• Infections: endocarditis, Lyme disease, Chagas disease
• Autoimmune conditions: SLE, rheumatoid arthritis
• Thyroid dysfunction
WHAT TYPE OF AV BLOCK
WHAT TYPE OF AV BLOCK
WHAT TYPE OF AV BLOCK
WHAT TYPE OF AV BLOCK
TREATMENT
 Sinus bradycardia needs treatment if symptomatic or hemodynamic
compromise results from the bradycardia.
- atropine is the first drug to be given as it is most useful to increase heart
rate.
- In case of persistent bradycardia despite atropine treatment, electrical
pacing is used.
giving a lecture to a medical school class. He woke up spontaneously. No
chest discomfort or
palpitations and no symptoms of sweating or nausea. Underlying
hypertension, treated with
Aspirin, Ramipril, and Diltiazem. An ECG performed on site by Magen David
Adom is attached.
After collecting a comprehensive history from the patient and connecting
him to the monitor,
what would be the most suitable first step in this case management?

LAST EXAM
1. Implantation of a permanent
pacemaker for sick sinus syndrome
2. Initiation of Amiodarone
treatment
3. Addition of low-dose Metoprolol
4. Stop Diltiazem
A 74-year-old woman is examined in the ER due to complaints
about
“missing heart beats” in the past 3 weeks. She denies chest pain,
shortness
of breath or sweating. Her medical history includes hypertension
and diabetes
mellitus that are well controlled. On examination: Blood pressure
155/90 mmHg,
cardiac examination revealed irregular pulse. Her ECG is shown.
Which of the following is the most likely diagnosis?

1. Atrial fibrillation
2. Complete Atrioventricular Block
3. Mobitz Type I Atrioventricular Block
4. Mobitz Type II Atrioventricular Block
episodes in the
last few weeks. His medical history includes hypertension and diabetes
mellitus that
are well controlled. On examination: Blood pressure - 125/90 mmHg, pulse
- 50. His
neurological examination is normal, head CT showed no abnormalities and
orthostatism
was not found. His ECG is attached. Which of the following is the
appropriate management?

1. Holter blood pressure

2. Stress echocardiography
3. Pacemaker implacement
4. CRTD
5. Follow-up
A 55 year old patient with hypertension treated with Lisinopril
presents to the ER
after episode of unconsciousness, he is hemodynamic stable.
Examination shows
the ECG below. What is the treatment in this patient?

1. Holter
2. Electorphysiologic examination
3. Pacemaker
4. ICD
5. Discontinue of ACE
inhibitor
A 55-year-old woman is admitted for evaluation after 2 episodes of
syncope during her
morning walks. She has no previous medical history and takes no
medications. Her ECG
is attached. What would be the best management?

1. Pacemaker implantation as early as possible

2. Coronary catheterization to rule out arterial occlusion as early as
possible
3. A 24-hours holter monitor
4. Heart rate monitoring with
an implantedmonitor 30 days
5. Tilt Test
the ER following a syncope episode at home. He is taking ACE inhibitors,
metformin, and
aspirin. On examination at the ER – fully conscious, pale, pulse 42 per
minute, blood
pressure 85/45 mmHg, room air saturation 92%. Labs – normal
electrolytes, normal
troponin (8 hours following his admission). Below is his ECG.
Which of the following is the most appropriate next step?

1. Intravenous dopamine
2. Observation with monitoring
since the patient is fully conscious
now
3. Temporary pacemaker,
followed by permanent
pacemaker
4. Adrenalin administration
once
 SINUS TACHYCARDIA
 Heart Rate > 100
 Narrow complex QRS.
 Regular
 Sinus means P wave present

and every QRS preceded by

P wave.
 SUPRAVENTRICULAR TACHYCARDIA (SVT)
ATRIOVENTRICULAR NODAL REENTRY TACHYCARDIA (AVNRT)

 Heart Rate > 150

 Narrow complex QRS
 Regular rhythm.
 Retrograde hidden P wave

(no apparent P wave).

 ATRIAL FIBRILLATION
 Narrow QRS complex.
 Absent P wave
 Irregular Irregular Rhythm.
 HR is variable May have rapid

Response if HR > 100.

NOTES ON AFIB
 Risk factors for developing AF include: age, hypertension, diabetes mellitus,
cardiac disease, sleep apnea, hyperthyroidism and acute alcohol intoxication.
(Smoking not a risk factor)

 Warfarin is the treatment of choice in case of valvular AF and in severe renal

failure. NOAC are used in non-valvular AF as long as kidney function is not
severe.

 Patients who are converted into sinus rhythm (either pharmacologically

or by DC shock) should receive a limited course of anticoagulation for at
least 4 weeks, since the risk for thromboembolism during the first weeks after
conversion remains relatively high, due to atrial stunning. Then Long-term
anticoagulation is indicated according to the CHADS-VASC score.
ATRIAL FLUTTER
VENTRICULAR
TACHYCARDIA
 VENTRICULAR
TACHYCARDIA
 Wide QRS complex
 Regular QRS and monomorphic shape

 Patient may have pulse

(Pulse-full V tach)
May not have pulse in arrest patients
(Pulseless V tach).
IMPORTANT
 In Ventricular tachycardia, the first step is to check pulse.

 If Pulseless V tach, proceed with ACLS algorithm for cardiac arrest.

 If pulse is present in V tach, the first question stable or unstable.

 Unstable Tachy-arrythmia, always synchronized cardioversion.

POLYMORPHIC
VENTRICULAR
TACHYCARDIA (TORSADES
DE POINTES)
 The same as Ventricular tachycardia but QRS has different shapes.
 Elongation of QT interval is associated with arrhythmias such as torsades-des-
pointes and ventricular tachycardia.
 Etiologies for long QT include:

- Congenital long QT syndromes

- Electrolyte abnormalities: hypocalcemia, hypokalemia, and hypomagnesemia
(the "three hypos").
- Drugs:
• Antiarrhythmic drugs from class Ia (Quinidine, disopyramide, and procainamide) and
class III (amiodarone, sotalol, and dofetilide).
• Antibiotics: macrolides, fluoroquinolones, and clindamycin.
• Antipsychotics: Haloperidol, phenothiazines, thioridazine, and ziprasidone.
- Endocrine disorders: hypothyroidism, hyperparathyroidism, and
pheochromocytoma.
 Accelerated idioventricular rhythm (AIVR) is a ventricular arrhythmia,
which is common after reperfusion therapy in patients with STEMI,
especially after fibrinolytic therapy.
 It is mostly benign and typically does not progress to other ventricular
arrhythmias. Therefore, no treatment is indicated and the patient
should just be monitored.
ECG OF WPW.
ARRYTHMIA IN WPW
 The recommended treatment for atrial fibrillation in patients with WPW
is procainamide.
 AF in these cases can be accompanied with fast ventricular response. In
case of hemodynamic instability, the treatment is with cardioversion. In the
case of stable patients, the treatment is with procainamide or ibutilide.
 Patients in high risk group will benefit from ICD:

1) patients who had MI more than 40 days ago with EF <0.3 or EF <0.35
with symptomatic heart failure
2) 2) patient that since their MI 5 days has passed with reduced LVEF, non-
sustained VT, and inducible sustained VT or VF.
WHAT IS THE RHYTHM
WHAT IS THE RHYTHM
WHAT IS THE RHYTHM
WHAT IS THE RHYTHM
WHAT IS THE RHYTHM
TORSADES DE POINTES
 LAST EXAM
A 76-year-old female patient arrives at your clinic due to complaints of
palpitations in recent
months. Past medical history is positive for hypertension and type 2
diabetes for ten years.
An echocardiogram demonstrated evidence of mild left ventricular
hypertrophy without
a valvular problem. The ECG chart is presented below.
Which of the following medications would be suitable in this case for long-
term treatment?

1. Ticagrelor
2. Rivaroxaban
3. Aspirin
4. Heparin
Which of the following presentation will have the most
benefit from
anticoagulation in case of atrial fibrillation?

1. A 64 year old male with hypertension

2. A 73 year old female with diabetes
3. A 76 year old female with stroke
4. A 78 year old male with hypertension
5.A 76 year old male with congestive heart Failure
year-old female
complaining of palpitations, malaise, blood pressure of 120/80, and
pulse 200/min
regular. Physical examination is normal. Below is her ECG. After
Valsalva maneuver,
the pulse decreases to 80/min and she improves clinically.
Which of the following is
the most likely diagnosis?

1. Rapid atrial fibrillation

2. Multifocal atrial tachycardia
3. Sinus tachycardia
4. Atrioventricular node reentry
tachycardia
for untreated hypertension. In the last few days, he was suffering from an
upper respiratory
illness and complained of a dry cough, rhinorrhea, and a sore throat. He did
not have a fever.
The patient describes having palpitations and dyspnea appearing suddenly
3 hours ago.
His vitals include: Pulse=130, BP=80/40mmHg, Fever=37.0c, O2 saturation
at room air=95%.
An ECG was performed, what is the next step?

1. Lidocaine
2. Amiodarone
3. Electric cardioversion
4. Metoprolol
5. Verapamil
A 57-year-old man, with no significant medical history, presents
with new-onset
atrial fibrillation. Trans-esophageal echocardiography (TEE) was
performed and
thrombi were not observed in the left atrium. Electrical
cardioversion was
successfully performed and he returned to sinus rhythm.
What is the appropriate treatment for this patient?

1. Anticoagulation therapy for a year

2. Anticoagulation therapy for 4 weeks
3. Amiodarone
4. Metoprolol
5. No need for further treatment
On examinations
he displays respiratory distress, diaphoresis, diffuse rales over the lungs,
normal rapid heart
sounds, irregular 160, blood pressure 80/50. O2 saturations 85 % with room
air. ECG attached.
What is the most appropriate treatment at this time?

1. Decrease heart rate with IV-Beta -blockers

2. Decrease heart rate with IV non-dihydropyridines calcium blockers
3. Immediate electrical cardioversion
4. Immediate medical cardioversion
with IV amiodarone
5. Non- invasive respiratory support
with BIPAP and IV furosemide
Upon admission he
appears anxious, BP 130/80, in ECG chart on admission there is evidence of
an anterior STEMI.
Fibrinolytic therapy with tissue plasminogen activator (tPA) was started with a
good response.
About two hours later, when preparing to transfer him to a medical center
that performs
percutaneous coronary interventions (PCI), the following arrhythmia was
observed.
What is the most correct statement regarding this type of arrhythmia?

1. This is a ventricular tachycardia (VT) with a poor prognosis - must be

treated immediately
with cardioversion
2. This is supraventricular tachycardia (SVT) with a good prognosis and can
be treated with
antiarrhythmic therapy
3. This is a nodal rhythm and a temporary pacemaker must be implanted
admitted due to
a urinary tract infection. During his admission, he complains of epigastric pain
and sweating.
ECG demonstrates ST elevation in V1-V4 and coronary catheterization is
performed with LAD
artery stenting. Two days following the catheterization the patient complains of
palpitation
and significant malaise. His blood pressure is 80/50 and the monitor shows the
following picture.
What is the most appropriate next step?

1. IV metoprolol
2. Immediate synchronized electrical cardioversion
3. IV amiodarone
A 67 year old female is found unconscious. On ECG ventricular
fibrillation (VF)
is identified. What is the treatment for VF?

1. Intubation
2. Epinephrine
3. Synchronized cardioversion
4. Unsynchronized cardioversion
5. Amiodarone
A 55-year-old woman, with no significant medical history, is
presenting to the
ER due to shortness of breath in the last few weeks, accompanied by
heart
palpitations. Her vital signs: BP - 140/75, pulse - 140, 98%
saturation, temp 36.6.
An ECG is attached. What is the appropriate immediate first
treatment?

1. IV metoprolol
2. IV Adenosine
3. IV Amiodarone
4. PO Anticoagulation
5. Electric cardioversion
A 76 years old female is brought to the ER due to generalized malaise
and palpitations.
These symptoms have been occurring episodically over the last week.
Blood
pressure 125/85 mmHg. An ECG is attached.
What is the appropriate treatment?

1. Electrical cardioversion
2. Cardioversion with amiodarone
3. Decrease heart rate with
beta blockers
4. Decrease heart rate with
digoxin
5. Cardioversion with
adenosine
A 50-year-old man complains of recurrent palpitations. On presentation, he
is hemodynamic
stable. His ECG is shown below.
What is the treatment in this patient in case atrial fibrillation starts?

1. Digoxin
2. Procainamide
3. Lidocaine
4. Verapamil
5. DC shock