June 2014 Underwriting Puzzler Answer

ECG Underwriting
Puzzler
Presented by: Bill Rooney, M.D.
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QUESTION????
How would you
ECGinterpret
Puzzlerthis ECG?
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If you said It looks normal other than for one PVC you were correct. PVC’s can
exist in many forms and configurations. Always be on the lookout!!
I will take you down the road of PVC’s and the mischief they can cause.
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The PVC can be seen in several leads below. It is the same PVC but seen from different
angles. PVC’s are early occurring beats
a wide (typically >0.16 sec) QRS complex.
ECGwith
Puzzler
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ECG Puzzler
If several PVC’s are present
and they all have the same
QRS morphology they are
called unifocal PVC’s. But, if
those PVC’s have different
QRS morphologies then they
are referred to as multifocal
PVC’s.
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The Many Faces of PVC’s
Single PVC
Bigeminy
Triplet PVC’s
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Multifocal PVC
Couplet
V-tach
QUESTION????
How would you interpret this ECG?
One more ECG to consider
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Is that artifact in leads I, II, and III or is it an abnormality?
What is that strange beat???
Answer:
The wide and bizarre beat, which is seen in multiple leads, is a PVC.
Other than the PVC the ECG looks to be WNL.
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Here is a rhythm strip from the previous slide
ECG Puzzler
Notice the
pause after
the PVC?
Single PVC
If the ventricle however is ready for the
impulse then the next normal QRS
complex occurs as scheduled and
causes the PVC to become
interpolated”.
Interpolated PVC’s are rare. The PVC
is “sandwiched” in between 2 normal
beats and there is no pause.
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This is called a “compensatory
pause”. The pause allows the
ventricles to reset and be ready for
the next impulse coming down from
the SA node.
The SA node continues to fire but the beat is not
conducted as the ventricle is just not ready for it yet.
The p wave gets buried in the QRS complex
somewhere.
PVC’s
There are no additional mortality
concerns with interpolated PVC’s
versus PVC’s with the
compensatory pause but it remains
important to be able to recognize
them.
For further reading:
Please see page 137 in Dale
Dubin’s 6th edition of Rapid
Interpretation of EKG’s
That concludes this issue of
the ECG Puzzler!! Contact
me if you have any
questions!!
ECG Solved
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