This is an autosomal dominant disease with variable penetration that is second only to HCM in causing sudden cardiac death in otherwise healthy young people. Dr. Burns presents basic ECG findings of ARVH as well as discussing other diagnostic studies and treatment. Highlights below.
There are several key differences in pediatric ECGs that would otherwise cause alarm in an adult ECG. Also check out life in the fast lane's page on pediatric ECGs
Axis: Rightward axis
Dr. Mattu reminds us that one ECG begats another. If something doesn't look or feel right, repeat the ECG. He sites a paper documenting 11% MI's not seen on initial ECG in a study of over 41K pt's! (Check out link below)
aVL, V2 depression can be reciprocal changes for inferior MI.
Diagnostic Time Course, Treatment, and In-Hospital Outcomes for STEMI Patients Presenting with Non-Diagnostic Initial ECG: A Report from the AHA Mission: Lifeline Program
Robert F. Riley, MD, L. Kristin Newby, MD, MHS, Creighton W. Don, MD, MSE, PhD, Matthew T. Roe, MD, MHS, DaJuanicia N. Holmes, MS, Sanjay K. Gandhi, MD, Michael A. Kutcher, MD, and David M. Herrington, MD, MHS
Dr. Mattu walks us through how to read an abnormal appear ECG and not miss the subtle MI. He recommends a logical, stepwise approach. By considering the differential of each abnormality seen you can begin to understand what is happening with the pt's heart. Finally, apply the filter of your final diagnosis and look for the subtle clues to ischemia.
1) Rate and Rhythm
Some differentials worth reviewing noted below.
Key definition: LAFB + RBBB = Bifascicular block
Dr. Smith urges us to know the Sgarbossa Criteria and advocate for our patients. Start with his blog post here:
The original criteria used to diagnose MI in patients with LBBB are:
Also check out the modified Sgarbossa Criteria from Dr. Smith's blog
Also check out this great summary from LITFL.
Specific for proximal LAD occlusion. Important not to miss as medical management typically not effective for proximal lesions, they need the cath lab.
Check out LITFL with a list of criteria for Wellen's per Rhinehart et al
2 criteria for low voltage:
1) QRS complex in I+II+III <15 mm
- or -
2) QRS complex in V1+2+3 <30 mm
Low voltage is either a 'weak battery' or there is something dampening the current reaching your leads.
Intrinsic low voltage:
- Infiltrative disease
- End stage cardiomyopathy
- Severe hypothyroidism
- Pericardial effusion
- Pleural effusion
If the low voltage is new, consider new onset severe hypothyroidism, pericardial or pleural effusions.
Our thanks to Dr. Tim Davie for assembling the Copa Cardiogram each week. Please follow this link to get to spreadsheet of all Copa Cardiograms.
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