ischaemic heart disease Curtis Li,Polymorphous ventricular tachycardia(Torsade de pointes).,A 60 year old man with Ischaemic Heart Disease,Polymorphous ventricular tachycardia (Torsade de pointes). This is a form of VT where there is usually no difficulty in recognising its ventricular origin. wide QRS complexes with multiple morphologies changing R - R intervals the axis seems to twist about the isoelectric line it is important to recognise this pattern as there are a number of reversible causes heart block hypokalaemia or hypomagnesaemia drugs (e.g. tricyclic antidepressant overdose) congenital long QT syndromes other causes of long QT (e.g. IHD) This recording has been kindly donated by Dr G. Butrous of St Georges Medical School London who is a cardiologist involved in EUROTOP.,A 55 year old man with 4 hours of “crushing“ chest pain. Acute inferior myocardial infarction ST elevation in the inferior leads II, III and aVF reciprocal ST depression in the anterior leads,A 63 year old woman with 10 hours of chest pain and sweating. Acute anterior myocardial infarction ST elevation in the anterior leads V1 - 6, I and aVL reciprocal ST depression in the inferior leads,A 60 year old woman with 3 hours of chest pain. Acute posterior myocardial infarction (hyperacute) the mirror image of acute injury in leads V1 - 3 (fully evolved) tall R wave, tall upright T wave in leads V1 -3 usually associated with inferior and/or lateral wall MI,A 53 year old man with Ischaemic Heart Disease. Old inferior myocardial infarction a Q wave in lead III wider than 1 mm (1 small square) and a Q wave in lead aVF wider than 0.5 mm and a Q wave of any size in lead II,A 79 year old man with 5 hours of chest pain. Acute myocardial infarction in the presence of left bundle branch block Features suggesting acute MI ST changes in the same direction as the QRS (as shown here) ST elevation more than youd expect from LBBB alone (e.g. 5 mm in leads V1 - 3) Q waves in two consecutive lateral leads (indicating anteroseptal MI),ventricular rhythms,A lady with Romano-Ward syndrome Long QT interval,Long QT interval,The QT interval normally varies with heart rate - becoming shorter at faster rates. It is usually corrected using the cycle length (R-R interval) as shown opposite. normal QTc = 0.42 seconds Romano-Ward syndrome is an autosomal dominantly inherited form of long QT interval and there is a risk of recurrent ventricular tachycardia, particularly Torsade de Pointes. Ventricular premature beats (VPBs) They are broad occur earlier than normal and are followed by a full compensatory pause (the distance between the normal beats before and after the VPB is equal to twice the normal cycle length).,A 50 year old man with chest pain for 24 hours Ventricular bigeminy a ventricular premature beat follows each normal beat There are also features of an acute inferior myocardial infarction,A 70 year old man with exercise intolerance Complete Heart Block P waves are not conducted to the ventricles because of block at the AV node. The P waves are indicated below and show no relation to the QRS complexes. They probe every part of the ventricular cycle but are never conducted. The ventricles are depolarised by a ventricular escape rhythm.,A 45 year old lady with palpitations and history of chronic renal fail Ventricular tachycardia,Ventricular tachycardia,A wide QRS tachycardia is VT until proven otherwise (1). Features suggesting VT include:- evidence of AV dissociation independent P waves (shown by arrows here) capture or fusion beats beat to beat variability of the QRS morphology very wide complexes ( 140 ms) the same morphology in tachycardia as in ventricular ectopics history of ischaemic heart disease absence of any rS, RS or Rs complexes in the chest leads (2) concordance (chest leads all positive or negative),A 69 year old man 2 weeks after an inferior myocardial infarction Ventricular tachycardia,Ventricular tachycardia,A wide QRS tachycardia is VT until proven otherwise (1). Features suggesting VT include:- evidence of AV dissociation independent P waves capture or fusion beats beat to beat variability of the QRS morphology (shown here) very wide complexes ( 140 ms) the same morphology in tachycardia as in ventricular ectopics history of ischaemic heart disease absence of any rS, RS or Rs complexes in the chest leads (2) concordance (chest leads all positive or negative),A 36 year old lady with recurrent blackouts Implantable cardioverter defibrillator,Implantable cardioverter defibrillator Most of this 12-lead recording is polymorphic ventricular tachycardia but, in the rhythm strip, the large deflection (arrowed) is the defibrillator discharging. Following the defibrillation a dual chamber pacemaker can be seen. OK so I cheated a little with this one as the odds of catching this on a 12-lead ECG recording are very slim indeed. This is a reconstructed 12-lead recording from an electrophysiology study testing the device after placement.,