(BQ) Part 2 book ECG rounds presents the following contents: An asymptomatic 30-year-old woman, 53-year-old woman with long-standing mitral valve prolapse, an 89-year-old gentleman with hypertension, presenting for routine follow-up, 45-year-old gentleman presents with dyspnea,...
Section II LEVEL 210 n DIFFICULTY LEVEL Case #51 An asymptomatic 30-year-old woman DIFFICULTY LEVEL n 211 QUESTION 51-1 What does the ECG reveal? 212 n DIFFICULTY LEVEL DIFFICULTY LEVEL n 213 ANSWER 51-1 What does the ECG reveal? The rate is slightly slower than 75 beats/min P waves are difficult to visualize but can be seen in leads V3, I, and II The PR interval is slightly prolonged at just greater than 200 milliseconds Hence, the rhythm is sinus rhythm with first-degree AV block The intervals are otherwise normal, as is the QRS frontal plane axis At a glance, there may appear to be low voltage Before settling on this diagnosis, however, look closely at the voltage standardization of recording, represented by the rectangle at the far left of the tracing and noted in the figure This rectangle corresponds to 10 mV The standard 12-lead ECG is recorded such that little box of vertical amplitude is equivalent to mV Thus, the standardization rectangle would be 10 little boxes tall, as shown in the figure When an ECG is recorded at “half-standard” voltage, little box is equivalent to mV, and the standardization rectangle would be little boxes tall, as shown in the figure Thus, this ECG does not represent low voltage, but rather is a normal tracing recorded at half standardization This case illustrates the importance of a systematic approach to ECG interpretation including an evaluation of recording quality and standardization Normal standardization Half standardization 214 n DIFFICULTY LEVEL Case #52 A 53-year-old woman with long-standing mitral valve prolapse DIFFICULTY LEVEL n 215 QUESTIONS 52-1 What abnormalities are present on this ECG? 52-2 How would these abnormalities affect the qualities of the murmur of mitral valve prolapse? 216 n DIFFICULTY LEVEL DIFFICULTY LEVEL n 217 ANSWERS 52-1 What abnormalities are present on this ECG? Sinus rhythm is present with frequent premature ventricular contractions in a bigeminal pattern—a premature ventricular contraction alternating with a sinus beat The axis is normal There is an early R-wave transition in the precordial leads with an R wave greater than an S wave in lead V2; normally, the transition from dominant S wave to dominant R wave occurs at lead V4 in the precordium There are nonspecific ST-segment and T-wave abnormalities in leads V3 to V6 52-2 How would these abnormalities affect the qualities of the murmur of mitral valve prolapse? The classic auscultatory findings of mitral valve prolapse include a midsystolic click and late systolic murmur that continues with constant intensity through S2 These findings are caused by redundant, billowing tissue of the myxomatous mitral valve, much like a parachute in the wind Maneuvers that increase left ventricular (LV) cavity diameter stretch the mitral valve annulus, leading to a decrease in the amount of redundant tissue (like a parachute being pulled taut), while decreasing LV cavity diameter has the opposite effect, increasing the amount of redundant tissue A smaller LV cavity will cause the prolapse to occur earlier in systole, moving the click closer to S1 and increasing the intensity of the murmur, while a large LV cavity has the opposite effect Given the tracing above, a shorter R–R interval, such as that between a native beat and a premature ventricular contraction, will lead to decreased LV filling and the click–murmur complex of mitral valve prolapse will occur earlier in systole Conversely, the longer R–R interval following a PVC will increase LV filling and move the click–murmur complex later in systole 218 n DIFFICULTY LEVEL Case #53 An 89-year-old gentleman with hypertension, presenting for routine follow-up DIFFICULTY LEVEL n 631 ANSWERS 149-1 What is the diagnosis? There is an irregularly irregular rhythm with both wide and narrow QRS complexes The rate is very rapid; on average, the rate is 180 to 190 beats/min, with some beats conducting as fast as 300 beats/min The axis is leftward and the QRS has a right bundle branch block morphology There are no signs of ischemia The differential diagnosis of a wide complex irregularly irregular tachycardia includes atrial fibrillation with preexisting bundle branch block or rate-related aberrant conduction, polymorphic ventricular tachycardia, or atrial fibrillation in the presence of an A-V bypass tract/ Wolff-Parkinson-White (WPW) syndrome The morphology of this tracing is not consistent with polymorphic ventricular tachycardia One may be tempted to call this atrial fibrillation with aberrancy, but note that some narrow QRS complexes occur at faster rates and some wide QRS complexes occur at slower rates If aberrant conduction were present, broad QRS complexes should occur predictably with faster rates, narrowing at slower rates The combination of irregularly irregular rhythm with varying QRS width unrelated to the rate is diagnostic of the WPW syndrome in the presence of atrial fibrillation Recall that the WPW syndrome involves simultaneous conduction down the AV node (which conducts slowly but recovers quickly) and down an extranodal bypass tract (which conducts quickly but recovers slowly) In sinus rhythm, this results in the typical appearance of a short PR interval with a delta wave In atrial fibrillation, rapid chaotic atrial impulses bombard the AV node and the bypass tract and each QRS complex will consist of some combination of summed conduction down the bypass tract and the AV node The relative conduction properties of these tissues determine the resulting rhythm, and, as in this case, it can result in varying QRS widths and rapid rates 149-2 What is the next step in management? Agents that block the AV node should be avoided, as blocking the AV node can lead to rapid conduction down the bypass tract and cardiovascular collapse If there is any clinical instability, the patient should receive DC cardioversion Otherwise, procainamide intravenously is the agent of choice 632 n DIFFICULTY LEVEL The same patient after DC cardioversion: DIFFICULTY LEVEL n 633 QUESTIONS 149-3 What is the diagnosis? 149-4 What is the next step in management? 634 n DIFFICULTY LEVEL DIFFICULTY LEVEL n 635 ANSWERS 149-3 What is the diagnosis? This ECG reveals the typical findings of WPW syndrome: a short PR interval less than 120 milliseconds in duration and a broad, slurred initial portion of the QRS called a delta wave The delta wave is the result of conduction down the bypass tract directly depolarizing ventricular myocardium In this case, the delta wave results in inferior Q waves in a “pseudo-infarct pattern.” The axis and orientation of the delta wave can give clues to the location of the bypass tract; in this case, the delta wave is negative in the inferior leads and lead VI, positive in V2 through V4, and isoelectric in the lateral precordial leads 149-4 What is the next step in management? Catheter ablation of the bypass tract is the treatment of choice for the WPW syndrome, particularly in this case where the bypass tract has been documented to conduct rapidly in the setting of atrial fibrillation causing syncope Cure rates with catheter ablation exceed 90% 636 n DIFFICULTY LEVEL Case #150 A 55-year-old gentleman presents with 10 minutes of crushing substernal chest pressure DIFFICULTY LEVEL n 637 QUESTIONS 150-1 What findings are present on this ECG? 150-2 Is ischemia present on this tracing? 150-3 What would you next? 638 n DIFFICULTY LEVEL DIFFICULTY LEVEL n 639 ANSWERS 150-1 What findings are present on this ECG? The rhythm is sinus bradycardia Axis and intervals are normal The T waves in leads V2, V3, and V4 appear tall and broad based, towering over the QRS complexes Very slight ST elevation is present in leads V1 and V2 The ST segments in leads II, III, and aVF, although isoelectric, have an abnormal morphology with subtle straightening in contrast to the normal concave appearance There is an inverted T wave in lead aVL 150-2 Is ischemia present on this tracing? Yes! This is an example of a very early presentation of ST-segment elevation myocardial infarction (STEMI) The first ECG changes associated with occlusion of an epicardial coronary artery are hyperacute T waves, seen here in the anterior T waves These occur within the first minutes and are followed thereafter by elevation of the ST segment The slight ST elevations in V1 and V2 seen in this tracing are likely the beginning of this evolution The hyperacute T waves of early myocardial infarction should be distinguished from the peaked T waves seen in hyperkalemia, which are narrow based, tall, and pointed The T waves seen in this case are broad based and tall, present in a defined coronary distribution 150-3 What would you next? Treatment for this patient should be the same treatment for any patient with STEMI, despite the fact that ST segments have yet to elevate Medical therapy may include nitrates, aspirin, morphine, and oxygen along with other antiplatelet and antithrombin therapies Urgent reperfusion should be explored, either with thrombolytics or cardiac catheterization This page intentionally left blank INDEX A Abdominal pain, 19 after meal, 32 female, 112 symptoms, cause of, 19 Abnormalities, ECG, 10, 11, 12, 14, 15, 16, 18, 197 arrhythmia, 32, 34, 35 asymptomatic man, 12, 210, 352–355 on ECG, 388–391 bradycardia, 297 breathlessness, 125 cardiac conduction system, 72, 74, 75 chest discomfort, 36 chest pain, 60, 61, 62, 63 chronic obstructive pulmonary disease (COPD), 31 congestive heart failure, 92, 94, 95 coronary artery, 25, 26, 27 cough, 36 cross-country runner, 96, 97 defibrillation, 56, 57, 58 diabetes, 20, 23 diet-controlled diabetes, 20 differential diagnosis for, 287, 508 first-degree AV block, 75 hypertension, 20, 120, 140, 143 hypertension/mitral regurgitation, 88, 89, 90 causes of, 91 knee arthroscopy, miscarriages, woman, 80, 83 ECG findings, 83 myocardial infarction, 24, 27, 151 nonischemic cardiomyopathy, 111 differential diagnosis, 109, 111 paroxysmal atrial fibrillation, radiofrequency ablation for, 84 presentation/baseline tracings, 287, 288 PR interval prolongation, 75 rhinorrhea, 36 routine follow-up, seizure disorder, 232, 233 severe epigastric bloating, 16 syncope, 55 T-wave, 237 ventricular hypertrophy, left electrocardiographic diagnosis of, 120, 122 Alcohol withdrawal, syndrome, 290 Amiodarone, 307 Amyloidosis, 237 Angiogram, 579 Anterolateral distribution, 275 Arm pain, 246 Arrhythmia, 201, 293, 517 evaluation of, 308 risk factors, 202 Arrhythmogenic right ventricular cardiomyopathy (ARVC), 595 Arthroscopy, knee, Ashman’s phenomenon, 202 Aspirin, chest pressure, 639 Atria interaction, 477 ventricles, intervention, 474–477 Atrial arrhythmia, 311 Atrial arrhythmias, 7, 161, 359 COPD, 160 Atrial contractions, 15 Atrial depolarization, 279 Atrial fibrillation (AF), 7, 43, 67, 201, 241, 423 fatigue, 340 history of, 380–383 Atrial flutter, 267, 293 diagnosis of, 293 sawtooth waves, 181 Atrial pacing beats, 412 heart rate, 275 Atrial tachycardia, 555 AV block dizziness, 613 Mobitz I/II, 431, 563 with P waves, 617 AV nodal blocking medications, 340–343 AV nodal reentrant tachycardia (AVNRT), 103 AV node dependent, 261 AV reentrant tachycardia (AVRT), 103 antidromic, 359 diagnosis of, 363 first-degree AV block, 587 orthodromic, 359 R–R interval, 451 AV synchrony, 477 B β-Blockers, 503 mitral stenosis, 135 Biventricular hypertrophy, 521 Bradycardia, 114, 115 diagnosis, 115 Breast cancer abnormalities, 495 with dyspnea, 492–495 Breathlessness, 124, 126, 436–439 flutter waves, 127 Breath, shortness, 336–339 Brugada criteria, 459 Brugada ECG, 447 Brugada syndrome, 39, 583 Brugada type II pattern, 543 Bundle morphology, right, 245 C Cardiac apex, 166 Cardiac arrest, 392–395, 568–571 abnormalities, 395 differential diagnosis, 607 ECGs, 392, 394 examination, 604–608 pre/post defibrillation, 556–559 sodium bicarbonate, 608 Cardiac auscultation, 241 Cardiac conduction system, 31, 74, 75, 525 Cardiac contour, abnormal on chest radiograph, 424 Cardiac findings, 302 Cardiac history, 488–491 Cardiac procedure, 564–567 clinical information, 567 pacemaker, 567 postprocedure tracing, 567 641 642 n INDEX Cardiac surgery, 364–367 sawtooth waves, 367 Cardiogenic shock, 368–371 Cardiomyopathy, 11 Cardiovascular collapse, 225 Cardiovascular effects, of cocaine, 111 Carotid sinus, 258 physiologic effect of, 261 pre- and post-treatment, 258 Catheter ablation of bypass tract, 635 Cerebral ischemia, 43 symptoms, cause of, 43 Chemotherapy, for lymphoma, 182 Chest discomfort, 36 abnormalities, ECG, 36 physical examination, 37, 38, 39 Chest fluttering, 100 AV reentrant tachycardia (AVRT), 103 diagnosis, 101, 102, 103 Chest pain, 48, 60, 62, 63, 128, 130, 146, 147, 174, 190, 304, 316–319, 348–351, 572–576 clinical diagnosis, 575 conduction abnormalities, 618 crushing substernal, 614–618 diagnosis, 145, 307 distant history of, 320–323 ECG, acute onset of, 576 self-limited chest pain, 147 smoker, 226 ST-segment elevation myocardial infarction, 624–627 substernal, 144, 194 T-wave abnormalities, differential diagnosis, 129 Wellens ECG, 147 Chest pressure abnormality, 481 crushing substernal, 636–639 inotropic therapy, 478–481 ischemia, 639 nitrates, aspirin, morphine, 639 P waves, 482 rhythm, 481 R-P/P-R intervals, 482 Cholecystectomy, 226 Cholecystitis, acute, 35 Chronic obstructive pulmonary disease (COPD), 31 atrial arrhythmias, 160, 161 for follow-up, 158 physical examination, 31 Chvostek’s signs, 222–225 Circumflex coronary artery, 51 Cocaine, cardiovascular effects, 111 Cocaine-induced vasospasm, 111 Conduction system, 443 Confusion complaining of, 396–399 multiple myeloma, 284 Congestive heart failure, history, 92, 94 Consciousness, loses, 56 Coronary angiogram, 229 Coronary angiography, 131, 207, 368–371 Coronary artery, 19, 25, 27, 175, 176, 177, 205–207 ECG, 176, 177 ECG findings, 176, 177 symptoms, 207 Coronary artery bypass grafting, 229, 584–587 Coronary artery disease differential diagnosis, 529 history of, 526–529 Coronary revascularization, 249 Cough, 36, 424 Crescendo-decrescendo systolic murmur, 52, 54 Cyanotic congenital heart disease, 518–521 D Death See Sudden unexplained death Defibrillation, 56, 58 Defibrillator, 104 Depression, complaining, 396–399 Dextrocardia, 391 Diabetes, 280, 572–576 clinical diagnosis, 575 diet-controlled, 20 ECG, abnormalities, 23 lower-extremity edema, 280 smoking history, 204 Diaphoresis, smoking history, 204 Diastolic murmur, fish-mouth appearance, 169 Diastolic rumbling murmur, 166 Digitalis toxicity, potential electrocardiographic manifestations, 156 Digoxin, 152, 154, 552–555 Digoxin toxicity, 555 Dizziness, 112, 276–279, 372–375, 404–407, 428–431, 470–473, 600–603, 610–613 abnormalities, 431 atrial rate, 613 AV block, 613 diagnosis, 473 escape rhythm, 473 ST-T wave, 428, 430 systolic dysfunction complaining of, 242 Dyslipidemia, 436 Dyspnea, 19, 28, 166, 234, 348–351, 492–495 abnormalities, 495 differential diagnosis, 495 distant history of, 238 on exertion, 400–403, 544–547 inotropic therapy, 478–481 at rest, 470–473 right bundle branch block, 414–417 smoker, 28 Dyspnea, exertional, 132, 134 diagnostic test, 135 medical management, 135 narrow-complex tachycardia, 135 Dyssynchrony, 297 E Echocardiogram, 166, 168, 169 interpretation, guidelines, 1–2 axis, chamber enlargement, findings, hypertrophy, infarction, intervals, ischemia, rate, rhythm analysis, synthesize, Ectopic atrial rhythm, 173 Ectopic atrial tachycardia, 103 Electrocardiogram voltage, 235, 236, 237 Electrolyte, 225 abnormalities, 15, 517 disturbances, 59 dyscrasia, management of, 435 Epigastric bloating, 16 Epigastric pressure, 596–599 Ewart’s sign, of dullness, 39 Exertion, 400–403 F Fatigue, 294, 420–423 abnormalities, 297, 423 arrhythmia, clinical consequences, 423 atrial fibrillation, 340–343 extreme, 404–407 multiple myeloma, 284 INDEX n 643 Fever, 312 differential diagnosis, 315 woman, 32 Flutter waves, 403 Follow-up, 408–412 Hyperthyroidism, 15 Hypertrophy, 201, 275 Hypocalcemia, 59, 225 Hypokalemia, 59, 271 Hypotension, 348–351 Hypothermia, 298, 534 H Hand weakness, 40, 42 ECG findings, 40 Heart block, 297 diagnostic of, 387 Heart failure, 283, 503, 525 Heart fluttering, 596–599 Heart pounding complaint of, 448–451 patient’s tachycardia, diagnosis for, 451 Heart, racing complains of, 178 management strategy, 181 rhythm disturbance, 179, 180, 181 Heart rate, 161 Heart rhythm, irregular, 254 Heart sound, on examination, 336–339 Hemoptysis, 324 distant history of, 238 Hernia, 488–491 His–Purkinje system, 335, 473, 563 Hoover’s sign, 31 Hospitalized patient, 466–469 differential diagnosis, 469 parkinsonian tremor, 469 P waves, 469 Hyperacute T waves, 379 Hypercholesterolemia severe jaw pain and vomiting, 186, 187, 188, 189 Hyperinflation, 31 Hyperkalemia, 79, 173, 435, 607 empiric treatment for, 571 Hypertension, 11, 76, 78, 142, 400–403, 588–591 differential diagnosis, 141, 143 follow-up, 20 and mitral regurgitation, 88 P waves, 591 rhythm, 591 routine, follow-up, 140 routine follow-up, 218 for routine primary care follow-up, 120 skipped beats, 162 treatment, 591 I I A-V block, 99 Implantable cardioverter-defibrillator (ICD), 456 Inferior infarction, 207 Inferoposterior distribution, 275 Intensive care unit, 514–517 Ischemia, 51 diagnosis, 51 distribution of, 49, 51 posterior wall, 51 reciprocal depression, 51 Ischemic attack, 529 Ischemic cardiomyopathy extreme axis, 459 implantable cardioverter-defibrillator (ICD), 456–459 R, RS, and QS complexes, 459 Ischemic heart disease, 11 J J point, ST-segment elevation, 71 Junctional bradycardia, 301 Junctional rhythms, 257 K Kidney disease, chronic, 76, 78, 568–571 tracing, 79 Knee arthroscopy, preoperative evaluation, L Left-axis deviation, differential diagnosis, 9, 10, 11 Left bundle branch block, 436 scoring system for diagnosis, 439 Left bundle branch block (LBBB) morphology, 95, 503, 627 Left ventricular (LV) cavity, 217 Left ventricular hypertrophy (LVH), 521 Lev’s syndrome, 11 Lidocaine, 307 Lightheadedness, 276–279, 356–359 Lung disease, 161 Lung hyperinflation, 31 Lyme disease, 315 Lymphoma chemotherapy for, 182 chest pain/cough/hypoxemia, 182 M Malaise, 404–407 Malignancy abnormalities, 455 differential diagnosis for, 455 treated with adriamycin, 452–455 Malignant arrhythmia, 189 Medication toxicity, 15 Metastatic breast cancer, with dyspnea, 492–495 Miscarriages, woman, 80 Mitral valve prolapse, 214 murmur of, 215, 216, 217 Mobitz type I, 315 Monomorphic ventricular tachycardia, 335 Morphine, 177 chest pressure, 641 Multifocal atrial tachycardia (MAT), 201, 423 See also Atrial fibrillation Multiple electrolyte abnormalities, 271 Murmur distant history of, 238 of mitral stenosis, 241 mitral valve prolapse, 215–217 Myocardial edema, 302 Myocardial infarction, 27, 177, 275 anterior, 500 in anteroseptal/lateral leads, 177 distant history of, 320–323 history of, 92, 242 routine follow-up, 24 R wave, differential diagnosis, 149, 150, 151 ST elevation ECG changes, 319 management of, 148, 150, 151 symptoms, 19 Myocardial injury, 19 Myocardial injury, acute, 307 Myocardial ischemia, 279 scoring system for diagnosis, 439 Myocardial ischemia, acute, 249 Myocardial oxygen, 267 heart rate, 229 Myocardium, 525 644 n INDEX N Nausea, 19, 170, 436–439 right bundle branch block, 414–417 smoking history, 204 Near-syncope, multiple episodes, 440–443 Neck/jaw discomfort, 19 Neck pounding, 250–253 Night sweats, 424–427 abnormalities, 427 Nitrates, chest pressure, 639 Nonischemic cardiomyopathy, 104, 110, 332–335, 372–375, 404–407 dizziness and lethargy, 372–375 Non-ST-segment elevation myocardial infarction (NSTEMI), 575 O Obstructive pulmonary disease, chronic, 198 Oral intake, 268 Osborn wave, 533, 534 Oxygen, supplemental, 177 P Pacemaker, 137, 138, 355, 380–383 A-V delay, 355 behavior of, 623 code governing, 411 dual-chamber, 139 malfunction, 623 needs, 443 Palpitations, 43, 46, 47, 124, 126, 132, 134, 328–331, 356–359, 420–423, 536–539, 552–555, 600–603 abnormalities, 423 abnormal morphology, 536 anterior MI, history of, 500–503 arrhythmia, clinical consequences, 423 blood pressure, 503 coronary disease, 264 distant history of, 238 ECG findings, 44, 46 emergency department, 258 pre- and post-treatment, 261 PR interval, 76 QRS complex, 536 rheumatic mitral stenosis, 620–623 smoker, 226 systolic dysfunction complaining of, 242 Paroxysmal atrial fibrillation, 152, 154 abnormalities, 85 PR and P–P intervals, 155 radiofrequency ablation for, 84, 86 serum electrolyte levels, 155 Percutaneous coronary intervention (PCI), 249 thrombolytic therapy, 249 Pericardial effusion, 427 Phenytoin, 233 Pleuritic chest pain, 116, 118, 324 differential diagnosis, 119 ST-segment elevation, 119 Pneumonia, 198 Polymorphic ventricular tachycardia, 599 Posterior descending coronary artery (PDA), 115 P–P interval, 15 P–QRS complex, 15 Premature ventricular contractions (PVCs), 47, 331 Presyncope, 76, 79 PR interval, 99 Pulmonary embolism, 185 clinical history/ECG, 185 massive, 327 treatment for, 327 Pulmonary hypertension, 169 Pulse, 162 Purkinje fibers, 75 P waves, 161 Reperfusion therapy, 175, 177 for acute myocardial infarction, 627 Repolarization pattern, 71 Respiratory failure abnormalities, 465 differential diagnosis, 465 tobacco uses, 462–465 Respiratory infection, upper, 368–371 Retrograde atrial activation, 587 Rheumatic fever, 132, 134, 315 distant history of, 238 history of, 132 Rheumatic mitral stenosis, 552–555 palpitations, history of, 620–623 Rhinorrhea, 190 Rhythm, 41, 136, 138, 139, 158, 160, 163, 267, 484–487 P waves, 487 R–R interval, 487 Rhythm disturbance, 181 Rhythm, regularly irregular, 96, 97, 99 Right bundle branch block (RBBB), 95 Right dominant patients, 115 Right ventricular hypertrophy (RVH), 339 Right ventricular myocardial infarction, 351 Routine follow-up, 8, 10, 272 RSR’ configuration, 207 RS wave, 23 Q S QRS complexes, 11, 22, 23, 95, 99, 103, 115, 127, 161 morphologies, 143, 383, 517 paced beats, 355 QS complexes, 407 R Rabbit ears, 119 Racing heart complaining of, 360–363 diagnosis, 363 Radiofrequency ablation, 181 Rash, 312 differential diagnosis, 315 Renal disease dialysis treatment, 170 electrolyte dyscrasia, 435 end-stage, 170 dialysis treatments, 432–435 tracing, 172–173, 435 Renal replacement therapy, 435 Sarcoidosis, 315 Seizure disorder, 230 Sepsis, intensive care unit, 514–517 Serum electrolyte levels, 155 Severe breathlessness, 376–379 Severe epigastric bloating, 16 Shock, 48 nonischemic cardiomyopathy, 104 Shoulder pain, 246 Silent myocardial infarction, 275 Sinus arrest, 533 Sinus bradycardia, 87, 169, 257, 379 Sinus P waves, 355 Sinus rhythm, 7, 19, 63, 119, 165, 177, 193, 217, 221, 233, 257, 262, 283, 287, 525, 529 with first-degree AV block, 213 heart rate, 271 Sinus tachycardia, 27, 51, 83, 103, 185, 197 differential diagnosis, 229 treatment, 35 INDEX n 645 Skipped beats, 496–499 atrial impulse, 499 differential diagnosis, 499 sinus P waves, 499 Smoker physical examination, 29 wheezes, diffuse, 28 Snowstorm, 504–508 differential diagnosis, 507 T-wave inversions, 507 Sodium/calcium (Na/Ca) exchanger, 155 Sodium/potassium adenosine triphosphatase (Na/K ATPase), 155 Somnolence, 298 S1-QIII-TIII pattern, 83, 185 Stroke, 43, 66, 67 history of, 64 ST-segment abnormalities differential diagnosis, 267 Substance abuse, history, 316–319 Sudden cardiac death cause of, 347 differential diagnosis, 347 family history, 344–347 Sudden unexplained death, 540–542 Supraventricular tachycardia (SVT), 103, 229, 451 Symptomatic bradycardia, 279 Syncopal episodes, at home, 384–387 QRS complexes, 387 symptomatic bradycardia, 387 Syncope, 52, 54, 294, 444–447, 510–513, 548–551, 560–563, 580–583, 628–632 abnormalities, 447, 563 cardiac conduction system, 563 crushing substernal, 614–618 DC cardioversion, 631–632 diagnosis, 447, 513, 632 distant history of, 320–323 episode of, 304 history of, 592–595 miscarriages, woman, 80, 82 diagnosis, 83 Mobitz type II A-V block, 513 physical examination findings, 53 treatment of, 513 Systolic dysfunction, 525 Systolic murmur, 55 T Tachycardia, 35, 229, 262, 332–335 narrow-complex, 135 with sinus P waves, 407 Tachycardia-induced cardiomyopathy, 423 Therapeutic hypothermia, 530–533 Thromboembolic stroke, risk of, 135 Thrombolytic medications ST-segment elevation myocardial infarction, 624–627 Thrombolytic therapy, 43, 177 Tobacco uses respiratory failure, 462–465 Trousseau’s signs, 222–225 T wave deflection merging, 271 T-wave, 23 T-wave inversions, 189, 237 U Upper epigastric discomfort, smoking history, 204 V Vagal maneuvers, 103 Vaughn-Williams class IB antiarrhythmic agent, 233 Ventricular bigeminy, 47 Ventricular depolarization, 59 Ventricular fibrillation, 156 Ventricular hypertrophy, 267, 399 Ventricular hypertrophy, left electrocardiographic diagnosis of, 120, 123 Ventricular pacemaker, 551 Ventricular septal defect, 319 Ventricular tachycardia (VT), 156, 407, 503, 555 diagnostic of, 323, 407 Ventricular trigeminy, 47 Vomiting, 19 W Weakness, 522–525 differential diagnosis, 525 ECG findings, 525 Weight loss, 268 Wellens syndrome, 147 Wenckebach block, 99 Wenckebach second-degree heart block, 315 Wenckebach-type heart block, 165 Wheezes, diffuse, 28, 30 Wolff -Parkinson-White (WPW) syndrome, 11, 151, 491, 525, 631 Word-finding difficulty, 40, 42 ... Interpret this ECG 54 -2 What electrolyte is most likely deranged, and what ECG findings are typical of this diagnosis? 22 4 n DIFFICULTY LEVEL DIFFICULTY LEVEL n 22 5 ANSWERS 54-1 Interpret this ECG The... standardization 21 4 n DIFFICULTY LEVEL Case # 52 A 53-year-old woman with long-standing mitral valve prolapse DIFFICULTY LEVEL n 21 5 QUESTIONS 52- 1 What abnormalities are present on this ECG? 52- 2 How.. .21 0 n DIFFICULTY LEVEL Case #51 An asymptomatic 30-year-old woman DIFFICULTY LEVEL n 21 1 QUESTION 51-1 What does the ECG reveal? 21 2 n DIFFICULTY LEVEL DIFFICULTY LEVEL n 21 3 ANSWER