Percutaneous coronary intervention PCI or throm- bolytic agents should not be given unless there is evidence from previous records that the LBBB is new, and treatment will depend on whether the plasma troponin level is elevated. The patient urgently needs an echocardiogram, and probably needs early cardiac catheterization with a view to aortic valve replacement. He will need long-term anticoagulants because of the atrial fibrillation. What might be the diagnosis of the underlying heart condition and what would you do?
Clinical interpretation The ventricular rate is not adequately controlled, though the downward-sloping ST segment depression suggests that he is taking digoxin. The horizontal ST segment depression suggests ischaemia. What to do Despite the ECG evidence of ischaemia, possible diagnoses include rheumatic heart disease, thyrotoxicosis, alcoholic heart disease, and other forms of cardiomyopathy.
The chest X-ray suggests severe mitral regurgitation. Echocardiography is necessary. The serum digoxin level must be checked and the digoxin dose increased if appro- priate. In addition to digoxin, the patient will need an angiotensin-converting enzyme inhibitor, a diuretic and, unless contraindicated, anticoagulants. Beta- blockers must be considered once his cardiac failure is controlled. What does his ECG show, and what would you do? What to do The patient should be given pain relief, and in the absence of the usual contraindica- tions should immediately be treated with aspirin, immediate percutaneous coronary intervention PCI or a thrombolytic agent.
If he was treated with streptokinase for his previous infarction, he should be given alteplase or reteplase on this occasion. He had no symptoms. What does this ECG show and what physical signs would you look for? The right axis deviation suggests left posterior hemiblock. What to do RBBB is seen in a small proportion of people with otherwise perfectly normal hearts. In the presence of a heart murmur, however, the possibility of an atrial septal defect should be considered. This is what this patient had.
The physical signs were a widely split pulmonary second sound which did not vary with inspiration this is typical of RBBB , and an ejection systolic murmur best heard at the left sternal edge.
On deep inspiration a soft diastolic murmur could be heard at the lower left sternal edge. The systolic murmur is a pulmonary flow murmur due to the extra flow through the right side of the heart, and the diastolic murmur that occurs on inspira- tion is a tricuspid flow murmur. Following opera- tion, the RBBB persisted. He was not aware of a fast heart rate and had had no chest pain. Apart from a rapid rate there were no cardiovascular abnormalities, but he looked a little jaundiced and had an enlarged spleen.
What to do Provided the patient is not in heart failure, it is always a good idea to identify the cause of an arrhythmia before treating it. The combination of an atrial arrhythmia, jaundice and splenomegaly suggests alcoholism. The patient needs anticoagulants, but his INR international normalized ratio may already be high. An echocardio- gram is needed to assess left ventricular function.
Carotid sinus massage will prob- ably increase the degree of atrioventricular block, but is unlikely to correct the arrhythmia. Digoxin, a beta-blocker or verapamil could be given in an attempt to control the ventricular rate.
After anticoagulation, cardioversion — either electrical or with flecainide — will be necessary. She had no previous history of breathlessness, and no chest pain. Examination revealed nothing, other than a rapid heart rate. A pulmonary angiogram was carried out as part of a series of investigations immediately after admission. What is the diagnosis? However, the fact that leads V1—V3 are affected suggests a right ventricular problem.
The pulmonary angiogram shows a large central pulmonary embolus and occlu- sion of the arteries to the right lower lung. Clearly something has happened: the sudden onset of breathlessness without pain suggests a central pulmonary embolus — with pulmo- nary emboli that do not reach the pleural surface of the lung there may be little pain.
In this patient, an echocardiogram and then a pulmonary angiogram demon- strated a large pulmonary embolus. Remember that sudden breathlessness with clear lung fields on a routine chest X-ray is always assumed to be due to a pulmonary embolus until proved otherwise. Heparin is essential; thrombolysis should be considered. What does the ECG show and how should the patient be treated?
Since the T wave inversion is in leads V1—V3 but not V4, the possibility of a pulmonary embolus must be considered. What to do The ECG changes do not meet the conventional criteria for percutaneous coronary intervention PCI or thrombolysis for myocardial infarction raised ST segments or new left bundle branch block , but the patient does need the full range of treatment for an NSTEMI — heparin, aspirin, clopidogrel, a beta-blocker, possibly a nitrate, and a statin.
Early angiography must be considered. First degree block is not an indication for temporary pacing, but the patient must be monitored in case higher degrees of block develop. He is untreated. Does his ECG help with his diagnosis and management? An alternative explanation might be poor lead positioning. What to do The ECG should be repeated, to ensure proper positioning of the chest leads. An echocardiogram and a chest X-ray are needed, to see if left ventricular impairment is responsible for the breathlessness, and stress echocardiography or perfusion imaging are needed, to investigate the chest pain.
The patient was cold, clammy and confused, and his blood pressure was unrecordable. What does the ECG show and what would you do? Here the regularity of the rhythm and the very broad complexes of bizarre configuration leave no room for doubt that this is vent- ricular tachycardia. What to do In cases of severe circulatory failure, immediate DC cardioversion is needed. The pain is characteristic of a myocardial infarction.
Apart from signs due to pain, the examination is normal. The rapidity of Q wave development is extremely variable, but the trace is certainly consistent with a 4 h history.
The depressed and downward-sloping ST segment in lead V2 suggests involvement of the posterior wall of the left ventricle. What to do Pain relief is the most important part of the treatment.
In the absence of contra- indications, the patient should be given aspirin immediately, and then percutaneous coronary intervention PCI or thrombolysis as soon as possible. The appearance of the ECG is characteristic of severe cardiac ischaemia. The lack of a tachycardia is surprising. He needs anticoagulation with aspirin and heparin, though his postoperative state may prevent this, and intravenous nitrates should be given cautiously.
He had not had any chest pain or dizziness. Apart from a slow pulse, there were no abnormalities on examination. What three abnormalities are present in this record and how would you treat the patient?
The left axis deviation indicates left anterior hemiblock. The poor R wave progression virtually no R wave in lead V3, a small R wave in lead V4, and a normal R wave in lead V5 suggests an old anterior infarction. What to do This patient needs a permanent pacemaker. He was worried — should he have been? There are, however, no T wave changes. The U waves are perfectly normal, and this pattern is common in athletes.
What to do Tell the student to buy a good book on ECG interpretation, but if reassurance is not enough, echocardiography could be used to measure the left ventricular thickness. His problem had begun quite suddenly a few weeks previously, when he had had a few hours of dull central chest discomfort. What do his ECG and the enlarged part of his chest X-ray show and what would you do?
Clinical interpretation The raised ST segments suggest an acute infarction, but the deep Q waves suggest that the infarction occurred at least several hours previously.
These ECG changes are therefore probably all old; the anterior changes might indicate a left ventricular aneurysm. Since the ECG is compatible with an old infarction it should be assumed that this diag- nosis is correct, and the patient should be treated for heart failure in the usual way with diuretics, angiotensin-converting enzyme inhibitors and beta-blockers.
Since the heart failure is clearly due to ischaemia he also needs aspirin and a statin. The upper ECG is his record at rest, and the lower one was taken during stage 1 of the Bruce exercise protocol 1. What do these ECGs show and what would you do? Nevertheless, with the story of exercise-induced chest pain a diagnosis of angina seems likely, and an exercise test is the appropriate next step. Even this light exercise level markedly increased the heart rate.
Both the inferior and the anterior chest leads show definite ischaemia, so widespread coro- nary disease is likely, possibly including the main stem of the left coronary artery. What to do This patient can be treated immediately with short- and long-acting nitrates, beta- blockers and calcium antagonists, but he also needs urgent coronary angiography with a view to percutaneous coronary intervention PCI or coronary artery bypass graft surgery.
Risk factors such as smoking, weight and hypercholesterolaemia must See p. His pulse feels irregular but there are no other abnormal signs. This was his ECG. The progressively increasing PR intervals followed by a nonconducted P wave represent second degree block of the Wenckebach Mobitz type 1 type.
The next nonconducted P wave followed by a conducted P wave with a long PR interval is second degree block of Mobitz type 2. The final beat, with the same prolonged PR interval, shows first degree block. The changing heart rate is presumably the cause of his attacks of dizziness. What to do Since this man has had no pain, and there is no evidence of ischaemia on the ECG, it is perhaps unlikely that coronary disease is responsible for the conduction problem.
You should always think about myocarditis, and about infiltrative diseases that might affect the bundle of His, but in a hypertensive patient the most likely cause of this sort of heart block is medication. He may well be taking either a beta-blocker or a calcium-blocker, and the first thing to do would be to discontinue these. However, the flutter-like activity is variable, and the QRS complexes are completely irregular, so this is atrial fibrillation.
The ST segments are normal, with no suggestion of digoxin effect, and the ventricular rate is not controlled, so the patient is probably not taking digoxin. Her thyroid function tests should be checked, and she needs an echocardiogram to assess heart size and left ventricular function. The heart rate needs to be controlled, and digoxin is the first drug to use.
Her heart failure must be treated with a diuretic and probably an angiotensin-converting enzyme inhibitor, and then a decision has to be taken regarding cardioversion. This is unlikely to be successful unless some remediable cause of the atrial fibrillation, such as thyrotoxicosis, is detected. At this age, she will need life-long anticoagula- tion with warfarin, whatever her echocardiogram shows. Does it help in making a diagnosis?
This rhythm is not uncommon, and is usually of no clinical significance. It is unlikely to be the cause of her symptoms unless at times she has a paroxysmal atrial tachycardia. What to do Take a careful history and attempt to determine whether her symptoms sound like a paroxysmal tachycardia — ask about any sudden onset and ending of the palpita- tions; associated symptoms like breathlessness; precipitating and terminating factors; and so on. If in doubt, some sort of ambulatory recording will be needed.
Any comments? A normal trace would be obtained with the limb leads reversed and the chest leads attached in the usual rib spaces but on the right side of the chest. What to do Ensure that the leads are properly attached — for example, inverted P waves in lead I will be seen if the right and left arm attachments are reversed. Of course, this would not affect the appearance of the ECG in the chest leads. No previous records are available. Does her ECG help her management? The ECG does not suggest digoxin toxicity, but nevertheless this is the most likely cause of her nausea.
The U waves may be normal, but raise the possibility of hypokalaemia. What to do Digoxin therapy should be temporarily discontinued, and her plasma potassium and digoxin levels should be checked.
These are his ECG and chest X-ray: what do they show and what might be the problem? There is upper-zone blood diversion, indicating heart failure. The rhythm change, together with the development of RBBB, could be due to a chest infection but is more likely to have been caused by a pulmonary embolus. The right-sided pleural effusion could also be due to either infection or embolism, but the patient clearly has heart failure because the effusions are bilateral although asymmetrical and there is diversion of blood flow to the upper zones of the lungs.
What to do In a postoperative patient, anticoagulation can always cause haemorrhage. Never- theless, the risk of death from a pulmonary embolus is so high that the patient should immediately be given heparin while steps are taken white blood cell count, sputum culture, CT scan to differentiate between a chest infection and a pulmonary embolus.
The pain had been present for 6 h. What do the ECG and X-ray show and what would you do? Clinical interpretation This ECG shows an acute inferior myocardial infarction, which often causes first degree block. The Q waves and raised ST segments are consistent with the story of 6 h of chest pain, and the first degree block is not important.
What to do Chest pain radiating through to the back has to raise the possibility of aortic dis- section, which can occlude the opening of the coronary arteries and so cause a myocardial infarction.
However, this is relatively rare compared with back pain associated with myocardial infarction, which is common. In this case, the chest X-ray suggests that blood has leaked into the left pleural cavity from a dissection of the aorta. Thrombolysis for the myocardial infarction is obviously contraindi- cated, and the patient needs immediate investigation by CT or MR scanning to see if surgical repair of the dissection is possible.
What does it show and what might be the problem? The extrasystoles are supraventricular because they have the same abnormal QRS pattern as the sinus beats; they are atrial in origin because each is preceded by a T wave of slightly different shape from the sinus beats. What to do The palpitations of which the patient complains may well be due to the extrasys- toles: it is important to ensure that they correspond to her symptoms.
RBBB in a young person may indicate an atrial septal defect, and she should have an echocar- diogram. What does it tell you about the murmur? The inverted T wave in lead V1 is normal at any age. A normal ECG helps to exclude serious causes of heart murmurs, but the record has not been very helpful in this case.
What to do If in doubt, an echocardiogram will show whether there is any important structural abnormality of the heart. What do you think has happened? The onset of atrial fibrillation may have been the cause or the consequence of the myocardial infarction, and the rapid ventricular rate will at least in part explain the pulmonary oedema.
The left anterior hemiblock is probably a consequence of the infarction. The patient may not have experienced pain because of his diabetes. He needs diamorphine, an intravenous diuretic, intravenous nitrates, and intravenous digoxin to control the ventricular rate — all with careful monitoring. Attention can then be turned to the treatment of his myocardial infarction. He will need anticoagulation with heparin.
How would you interpret the ECG and what action would you take? In this patient, the exercise test was perfectly normal, and his symptoms cleared without any intervention.
A repeat ECG, recorded purely out of interest a month later, showed similar changes. What does the ECG show? What other investigations would you order? What to do If the patient gives a history suggestive of a myocardial infarction and has this ECG, no further investigations are needed in the acute phase of the illness, and in parti- cular there is no place for a chest X-ray. Routine treatment for a myocardial infarction — pain relief, aspirin and percutaneous coronary intervention PCI or thrombolysis — should be commenced immediately.
What are the palpitations due to, and what would you do? The ST segment depression could indicate ischaemia, but the ST segments are not horizontally depressed, nor is the depression greater than 2 mm, so it is probably of no significance. What to do The first action is carotid sinus pressure, which may terminate the attack. If this fails it will almost certainly respond to adenosine. As with any tachycardia, electrical cardioversion must be considered if there is haemodynamic compromise.
Once sinus rhythm has been restored, the patient must be taught the various methods e. Prophylactic medication may not be needed if attacks are infrequent, but most patients with this problem should have an electrophysiological study to try to identify a re-entry pathway that can be ablated.
She was anxious, but there were no abnormalities on examination. Does this ECG help with her diagnosis and management? The ECG does not help with the diagnosis and management. What to do If a full history and examination fail to suggest any underlying physical disease, further investigations are unlikely to be helpful.
His jugular venous pressure is raised. What do you think the problem is? The peaked P waves indicate right atrial hypertrophy. The right axis deviation and dominant R wave in lead V1 suggest right ventricular hypertrophy. These changes suggest lung disease. The story sounds more in keeping with a lung problem.
The raised jugular venous pressure is presumably due to cor pulmonale. The sinus tachycardia is worrying, and suggests respiratory failure. He had had no chest pain. Examination revealed a raised jugular venous pressure, basal crackles in the lungs and a third sound at the cardiac apex. These are his ECG and chest X-ray. What do they show and how does this fit the clinical picture? Clinical interpretation This ECG would be compatible with an acute anterior myocardial infarction, but this does not fit the clinical picture: it appears that an event occurred 2 months previously.
This pattern of ST segment elevation in the anterior leads can persist following a large infarction, and is often seen in the presence of a ventricular aneur- ysm. This is confirmed by the chest X-ray. What to do An echocardiogram will show the extent of the aneurysm and whether the remaining left ventricular function is impaired, which it almost certainly will be. The patient should be treated with diuretics and an angiotensin-converting enzyme inhibitor, and surgical resection of the aneurysm might be considered.
What has the house officer missed? Perhaps he did not make a proper examination and did not look at the chest X-ray? Clinical interpretation The broad QRS complexes show that this is either a supraventricular rhythm with bundle branch block, or a ventricular rhythm.
This rhythm is ventricular. The sharp spikes preceding each QRS complex are due to the pacemaker. The P waves that can occasionally be seen indicate that the underlying rhythm is complete heart block — presumably the reason why the pacemaker was inserted. What to do The house officer has missed the pacemaker, which is usually buried below the left clavicle.
There is no particular reason why the pacemaker should be related to the stroke, except that patients with vascular disease in one territory usually have it in others — this man probably has both coronary and cerebrovascular disease.
There are three abnormalities. What advice would you give her? Permanent pacing is essential. What happened and what would you do?
What to do Precordial thump and immediate defibrillation, but if no defibrillator is at hand then cardiopulmonary resuscitation should be performed, and the usual procedure for the management of cardiac arrest instituted. What has happened and what would you do? Here the very broad complexes and the QRS complex concordance suggest a ventricular tachycardia. In a patient with a myocardial infarction it is always safe to assume that such a rhythm is ventricular. From the story, one would guess that this patient had a myocardial infarction and then developed ventricular tachycardia, but it is possible that the chest pain was due to the arrhythmia.
What to do This patient has haemodynamic compromise — low blood pressure and heart failure — and needs immediate cardioversion. While preparations are being made it would be reasonable to try intravenous lidocaine or amiodarone. These are his ECGs at rest upper trace and on exercise lower trace. What do they show? The S wave in lead V6 suggests the possibility of chronic lung disease. The risk factors for coronary disease must be assessed and treated, whatever course of action is chosen.
The ventricular rate is not well controlled. The ST segment depression suggests that she is taking digoxin. An echocardiogram should be recorded to check her heart size and left ventricular function; remember that atrial fibrillation may be the only indication of thyrotoxi- cosis in the elderly. Her complaint of palpitations may be due to her atrial fibrillation or to the extrasystoles or both. The extrasystoles themselves are not important, but she should avoid smoking, alcohol and caffeine.
A beta-blocker may reduce the extrasystoles as well as control her ventricular rate. It is unlikely that cardioversion would be successful, and she will need long-term treatment with digoxin, possibly a beta-blocker, probably an angiotensin-converting enzyme inhibitor, and certainly anticoagulants. What do you think the underlying disease was, and what were the palpitations due to?
The atrial fibrillation is probably secondary to the lung disease, though the other possibilities must be considered. What to do Stop the beta-agonist but do not give a beta-blocker. Check the electrolyte levels; consider the possibility of digoxin toxicity. His thyroid function tests, measured several times, were normal.
What might be going on? His diastolic blood pressure was high, which should not happen with anxiety. He was not thyrotoxic but there must have been some other physical cause of his problems — it turned out he had a phaeochromocytoma. Otherwise he is well, and there are no abnormalities on examination. Does this ECG help with his management? What to do Bifascicular block is not an indication for pacing if the patient is asymptomatic.
The problem here is to decide if the attacks of dizziness are due to intermittent complete heart block. Ideally an ECG would be recorded during an attack — since they occur only every week or so, ambulatory ECG recording may not be helpful, but an event recorder would be worth trying.
In the absence of clear evidence, the decision whether or not to insert a permanent pacemaker is a matter of judgement, but in a patient with this story and ECG it would be a perfectly reasonable thing to do. What does it show, and what would you do?
What to do This man is a professional football player, so it is important to exclude hypertrophic cardiomyopathy, and this can be done by echocardiography.
Because his career depended upon coronary disease being excluded, a coronary angiogram was per- formed and was entirely normal. Wednesday, July 15, Get help. Pick A PDF. Medical Cardiology. Please enter your comment! Please enter your name here. Sis abby Gaming Video Creator.
Free medical E books Bookstore. Medical books Bookstore. Published Date: 17th September Page Count: Free Shipping Free global shipping No minimum order. The role of the ECG in clinical practice.Jump to. Sections of this page. Accessibility Help. Email or Phone Password 150 ecg problems 4th edition pdf free download account? Sign Up. Log In. Forgot account? Not Now. Related Pages. Medical e-books for free download Book. Medical books free download Education Website. Sis abby Gaming Video Creator. Free medical E books Bookstore. Medical books Bookstore. ECG. PROBLEMS. John R. Hampton. Emeritus Professor of Cardiology First edition ECG in Practice, 4th edn, respectively (written by Professor time he was seen in the A & E department he was pain-free and there were no. ECG Problems [by Jhon R. Hampton] pdf (4th edition) spacesdoneright.comshare/kr61MftzG5Wmor. Medical book PDF Free Download Direct Link. Book. Helius and Chartwell Illustrators ECG Problems FOURTH EDITION John R. Hampton DM MA DPhil FRCP FFPM FESC Emeritus Professor of Cardiology. This article contains ECG Problems 4th Edition PDF for free download. This book has been authored by John Hampton DM MA DPhil. ECG Problems E-Book 4th Edition, Kindle Edition eBook features: Page Flip: Enabled; Due to its large file size, this book may take longer to download Read with the free Kindle apps (available on iOS, Android, PC & Mac), Kindle. *FREE* shipping on qualifying offers. ECG ECG Problems 4th Edition. by John Get your Kindle here, or download a FREE Kindle Reading App. Request PDF | On Jun 23, , Rasa Ordiene and others published Book Review: " ECG Problems" (Fourth edition) | Find, read and cite all the research. ECG Cases presents clinical problems in the shape of simple case histories together with the relevant ECG. Detailed Add to Cart. VitalSource eBook. Read " ECG Problems E-Book" by John Hampton, DM, MA, DPhil, FRCP, FFPM, FESC available from Rakuten Kobo. This book offers lead ECGs. The remainder should challenge the MRCP candidate. On the back the case is examined, with a description of the main features of the ECG along with a clinical interpretation and a "what to do" section. Disclaimer About Contact. Evidence of left ventricular hypertrophy may point to hypertension, mitral regurgitation or aortic stenosis or regurgitation, and right ventricular hypertrophy may be the result of pulmonary emboli or mitral stenosis — however, all of these should have been detected during the examination of the patient. John R. Follow Us. No comments:. It then invites the reader to interpret the ECG in the light of the clinical evidence provided, and to decide on a course of action before looking at the answer. Post a Comment. The book has also been praised for its high-yield and comprehensive content by the British Medical Journal. Type :pdf.