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Bundle Branch Block and the Imitators of ACS PowerPoint Presentation
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Bundle Branch Block and the Imitators of ACS

Bundle Branch Block and the Imitators of ACS

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Bundle Branch Block and the Imitators of ACS

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  1. MODULE 6 Bundle Branch Block and the Imitators of ACS

  2. Bundle Branch Block • Can be pre-existing condition • Can be caused by ACS

  3. Bundle Branch Block • BBB caused by AMI • 60%-70% association with pump failure • 40%-60% mortality without reperfusion

  4. Bundle Branch Block • Can mimic ACS • Can hide evidence of ACS

  5. May Produce ST elevation ST depression Tall T waves Inverted T waves Wide Q waves May Hide ST elevation ST depression Tall T waves Inverted T waves Wide Q waves Bundle Branch Block

  6. The Problem • Critical to reperfuse patients with BBB produced by ACS • ACS harder to identify on ECG when BBB present

  7. The Solution • BBB Problem • New or presumably new BBB is an indication for fibrinolytic therapy

  8. The Solution Fibrinolytic Therapy Trialists’ (FIT) Collaborative Group, 1994

  9. BBB Recognition Forget About the Notch!

  10. BBB Recognition • Wide QRS • > 120ms • Supraventricular rhythm

  11. BBB Recognition

  12. RBBB vs LBBB • RBBB in V1

  13. RBBB vs. LBBB • LBBB in V1

  14. RBBB vs. LBBB • Use V1 • Identify direction of terminal force

  15. Bundle Branch Block • V1

  16. BBB Recognition

  17. BBB Recognition

  18. BBB New onset BBB, or presumably new BBB, is an indication for acute reperfusion therapy

  19. Ventricular Rhythms • Paced rhythms • Idioventricular rhythms • AIVR • V-Tach • PVC

  20. Ventricular Rhythms • Can mask or mimic every ECG change suggestive of ACS

  21. Ventricular Rhythms

  22. Left Ventricular Hypertrophy • Enlarged left ventricle • Pumping against increased resistance • Chronic overfilling

  23. May Produce ST elevation ST depression Tall T waves Inverted T waves May Hide ST elevation ST depression Tall T waves Inverted T waves LVH

  24. LVH • Does not abnormally widen QRS • Increases height and depth of QRS • Recognized by this increase • Three step recognition formula

  25. LVH

  26. LVH Recognition • Step 1 • Look in V1 and V2 • Pick the deepest negative deflection • Count small boxes of negative deflection in that lead • Remember that number

  27. LVH

  28. LVH Recognition • Step 2 • Look in V5 and V6 • Pick the tallest positive deflection • Count small boxes of positive deflection • Remember that number

  29. LVH Recognition • Step 3 • Add the two numbers together • Suspect LVH if the sum equals 35 or more

  30. LVH

  31. LVH

  32. Ventricular Aneurysm • NOT Aortic Aneurysm • “Bleb” in ventricle secondary to infarct • Bleb is dyskinetic • “Pops out” when ventricle contracts

  33. Ventricular Aneurysm

  34. Ventricular Aneurysm • Associated with persistent ST elevation • Often in V1-V4 • Can occur in any lead

  35. Ventricular Aneurysm

  36. Benign Early Repolarization

  37. Benign Early Repolarization • Normal variant • Produces • ST elevation • Tall T waves

  38. Benign Early Repolarization • Changes usually seen in anterior and lateral leads • Most often seen in males ages 20-40 • African-American males

  39. Benign Early Repolarization • Look for notch at J-point • ST segment and J-point create a “fish hook” appearance

  40. Benign Early Repolarization

  41. Pericarditis

  42. Pericarditis • May be viral, bacterial or metabolic • Clinical presentation may include chest pain • Often produces ST elevation on ECG

  43. Pericarditis • Clinical presentation • Sharp chest pain • Can be localized • Radiates to base of neck, between shoulder blades

  44. Pericarditis • Pain affected by movement and respiration • Pain improves when patient leans forward • Pain worsens when patient supine

  45. Pericarditis • May produce ST elevation in any lead • May be in all leads • May not be anatomically grouped • J-point notching often present • Fish hook

  46. Medications • Some medications affect the ECG • Digitalis • ST depression • Characteristic sag

  47. Digitalis Effect

  48. Summary • Imitators can produce ST elevation or depression • Imitators can eliminate ST elevation or depression

  49. Summary • Imitators can produce T wave inversion • Imitators can hide T wave inversion