![Rajiv Gandhi University of Health Sciences
D.M. Degree Examination - JULY-2018
[Time: 3 Hours] [Max. Marks: 100]
Cardiology - PAPER – I
Basics Sciences
QP Code: 9111
Your answers should be specific to the questions asked.
Draw neat, labeled diagrams wherever necessary. Answer all questions
LONG ESSAY (These questions carry 10 marks each) 10 X 10 = 100 Marks
1. Briefly discuss S2 in health and disease.
2. Pulsus Alternans and Pulsus Bisifierens
3. ECG in Chamber enlargement
4. ECG abnormalities in Electrolyte Abnormalities
5. Assessment of RV function
6. Ankle Brachial Index
7. Myocardial Hibernation
8. Dynamic Auscultation
9. ECHO assessment of Restrictive Cardiomyopathy
10. Abdomino Jugular Reflux](https://image.slidesharecdn.com/basicsofecg-230310184646-62c80ea0/85/Basics-of-ECG-ppt-79-320.jpg)
Basics of ECG.ppt
- 2. Outline 1. Review of the conduction system 2. ECG leads and recording 3. ECG waveforms and intervals 4. Normal ECG and its variants 5. Interpretation and reporting of an ECG
- 4. What is an ECG? The electrocardiogram (ECG) is a representation of the electrical events of the cardiac cycle. Each event has a distinctive waveform, the study of which can lead to greater insight into a patient’s cardiac pathophysiology.
- 5. Useful in diagnosis of… Cardiac Arrhythmias Myocardial ischemia and infarction Pericarditis Chamber hypertrophy Electrolyte disturbances Drug effects and toxicity
- 8. Basics ECG graphs: –1 mm squares –5 mm squares Paper Speed: –25 mm/sec standard Voltage Calibration: –10 mm/mV standard
- 9. ECG Paper: Dimensions 5 mm 1 mm 0.1 mV 0.04 sec 0.2 sec Speed = rate Voltage ~Mass
- 10. ECG Leads Leads are electrodes which measure the difference in electrical potential between either: 1. Two different points on the body (bipolar leads) 2. One point on the body and a virtual reference point with zero electrical potential, located in the center of the heart (unipolar leads)
- 11. + - RA RA LL + + - - LA LL LA LEAD II LEAD I LEAD III Remember, the RL is always the ground • By changing the arrangement of which arms or legs are positive or negative, three unipolar leads (I, II & III ) can be derived giving three "pictures" of the heart's electrical activity from 3 angles. The Concept of a “Lead” Leads I, II, and III I II III
- 12. ECG Leads The standard ECG has 12 leads: 3 Standard Limb Leads 3 Augmented Limb Leads 6 Precordial Leads The axis of a particular lead represents the viewpoint from which it looks at the heart.
- 20. All Limb Leads
- 21. Precordial Leads
- 22. Precordial Leads
- 23. Summary of Leads Limb Leads Precordial Leads Bipolar I, II, III (standard limb leads) - Unipolar aVR, aVL, aVF (augmented limb leads) V1-V6
- 25. Hexaxial Reference system in frontal plane
- 26. Arrangement of Leads on the EKG
- 32. Localising the arterial territory Inferior II, III, aVF Lateral I, AVL, V5-V6 Anterior / Septal V1-V4
- 33. Interpretation of an ECG
- 34. Steps involved Heart Rate Rhythm Axis Wave morphology Intervals and segments analysis Chamber enlargement Specific changes
- 35. Determining the Heart Rate Rule of 300 10 Second Rule
- 36. Rule of 300 Take the number of “big boxes” between neighboring QRS complexes, and divide this into 300. The result will be approximately equal to the rate Although fast, this method only works for regular rhythms.
- 37. The Rule of 300 It may be easiest to memorize the following table: # of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50
- 38. 10 Second Rule As most ECGs record 10 seconds of rhythm per page, one can simply count the number of beats present on the ECG and multiply by 6 to get the number of beats per 60 seconds. This method works well for irregular rhythms.
- 39. The QRS Axis The QRS axis represents the net overall direction of the heart’s electrical activity. Abnormalities of axis can hint at: Ventricular enlargement Conduction blocks (i.e. hemiblocks)
- 40. The QRS Axis By near-consensus, the normal QRS axis is defined as ranging from -30° to +90°. -30° to -90° is referred to as a left axis deviation (LAD) +90° to +180° is referred to as a right axis deviation (RAD)
- 41. Determining the Axis The Quadrant Approach The Equiphasic Approach
- 43. The Quadrant Approach 1. Examine the QRS complex in leads I and aVF to determine if they are predominantly positive or predominantly negative. The combination should place the axis into one of the 4 quadrants below.
- 44. The Quadrant Approach 2. In the event that LAD is present, examine lead II to determine if this deviation is pathologic. If the QRS in II is predominantly positive, the LAD is non-pathologic (in other words, the axis is normal). If it is predominantly negative, it is pathologic.
- 46. Example 1 Negative in I, positive in aVF RAD
- 47. Example 2 Positive in I, negative in aVF Predominantly positive in II Normal Axis (non-pathologic LAD)
- 48. The Equiphasic Approach 1. Determine which lead contains the most equiphasic QRS complex. 2. The overall QRS axis is perpendicular to the axis of this particular lead 3. Examine the QRS complex in whichever lead lies 90° away from the lead identified in step 1 4. If the QRS complex in this second lead is predominantly positive, than the axis of this lead is approximately the same as the net QRS axis 5. If the QRS complex is predominantly negative, than the net QRS axis lies 180° from the axis of this lead.
- 49. -90° -60° -30° 0° aVL I 30° 60° aVR II 90° 120° III 150° 180° -150° -120° aVF Marked RAD LAD RAD Normal Axis -30° to +100°
- 50. Example 1 Equiphasic in aVF Predominantly positive in I QRS axis ≈ 0°
- 51. Example 2 Equiphasic in II Predominantly negative in aVL QRS axis ≈ +150°
- 52. Using leads I, II, III LEAD 1 LEAD 2 LEAD 3 Normal UPRIGHT UPRIGHT UPRIGHT Physiologic al Left Axis UPRIGHT UPRIGHT / BIPHASIC NEGATIVE Pathological Left Axis UPRIGHT NEGATIVE NEGATIVE Right Axis NEGATIVE UPRIGHT BIPHASIC NEGATIVE UPRIGHT Extreme Right Axis NEGATIVE NEGATIVE NEGATIVE
- 53. Common causes of LAD May be normal in the elderly and very obese Due to high diaphragm during pregnancy, ascites, or ABD tumors Inferior wall MI Left Anterior Hemiblock Left Bundle Branch Block WPW Syndrome Congenital Lesions RV Pacer or RV ectopic rhythms Emphysema
- 54. Common causes of RAD Normal variant Right Ventricular Hypertrophy Anterior MI Right Bundle Branch Block Left Posterior Hemiblock Left Ventricular ectopic rhythms or pacing WPW Syndrome
- 55. Normal Axis Normal Axis = -30 to +120 RAD =+120 to +180 LAD = -30 to -90 • LAD • Anterior Hemiblock • Inferior MI • WPW – right pathway • Emphysema • RAD • Children, thin adults • RVH • Chronic Lung Disease • WPW – left pathway • Pulmonary emboli • Posterior Hemiblock • No Man’s Land • Emphysema • Hyperkalemia • Lead Transposition • V-Tach No Man’s Land Axis = -90 to +- 180
- 56. The Normal ECG
- 57. Normal Sinus Rhythm Originates in the sinus node Rate between 60 and 100 beats per min P wave axis of +45 to +65 degrees, ie. Tallest p waves in Lead II Monomorphic P waves Normal PR interval of 120 to 200 msec Normal relationship between P and QRS Some sinus arrhythmia is normal
- 58. Sinus Arrhythmia ECG Characteristics: Presence of sinus P waves Variation of the PP interval which cannot be attributed to either SA nodal block or PACs When the variations in PP interval occur in phase with respiration, this is considered to be a normal variant. When they are unrelated to respiration, they may be caused by the same etiologies leading to sinus bradycardia.
- 59. Normal P wave Atrial depolarisation Duration 80 to 100 msec Maximum amplitude 2.5 mm Axis +45 to +65 Biphasic in lead V1 Terminal deflection should not exceed 1 mm in depth and 0.03 sec in duration
- 60. Normal QRS complex Completely negative in lead aVR , maximum positivity in lead II rS in right oriented leads and qR in left oriented leads (septal vector) Transition zone commonly in V3-V4 RV5 > RV6 normally Normal duration 50-110 msec, not more than 120 msec Physiological q wave not > 0.03 sec
- 61. Normal T wave Same direction as the preceding QRS complex Blunt apex with asymmetric limbs Height < 5mm in limb leads and <10 mm in precordial leads Smooth contours May be tall in athletes
- 62. ST segment Merges smoothly with the proximal limb of the T wave Does not ‘hug’ the baseline No true horizontality
- 63. Normal u wave Best seen in midprecordial leads Height < 10% of preceding T wave Isoelectric in lead aVL (useful to measure QTc) Rarely exceeds 1 mm in amplitude May be tall in athletes (2mm)
- 64. QT interval Normally corrected for heart rate Bazett’s formula Normal 350 to 430 msec With a normal heart rate (60 to 100), the QT interval should not exceed half of the R-R interval roughly
- 65. Normal Variants in the ECG
- 66. Sinus arrhythmia Persistent juvenile pattern Early repolarisation syndrome Non specific T wave changes
- 67. Features of ERPS Vagotonia / athletes’ heart Prominent J point Concave upwards, minimally elevated ST segments Tall symmetrical T waves Prominent q waves in left leads Tall R waves in left oriented leads Prominent u waves Rapid precordial transition Sinus bradycardia Early Recognition Prevents Streptokinase infusion !
- 68. Normal T wave changes Inverted in V1-V3: Persistent juvenile pattern Inverted normally in Anxiety Hyperventilation Orthostatic Postprandial
- 69. Reporting an ECG
- 70. 1. Patient Details “ Whose ECG is it ?!”
- 71. 2. Standardisation and lead placement “Is it properly taken ?” Look for technical Dextrocardia LV or RV leads?
- 72. 3. Analysis of Rate, Rhythm and Axis
- 73. 4. Segment and wave form analysis
- 75. 6. Other specific points of interest based on case history
- 76. Final Impression “ Does the ECG correlate with the clinical scenario ?”
- 77. Treat the patient and not the ECG !
- 78. Thank you !
- 79. Rajiv Gandhi University of Health Sciences D.M. Degree Examination - JULY-2018 [Time: 3 Hours] [Max. Marks: 100] Cardiology - PAPER – I Basics Sciences QP Code: 9111 Your answers should be specific to the questions asked. Draw neat, labeled diagrams wherever necessary. Answer all questions LONG ESSAY (These questions carry 10 marks each) 10 X 10 = 100 Marks 1. Briefly discuss S2 in health and disease. 2. Pulsus Alternans and Pulsus Bisifierens 3. ECG in Chamber enlargement 4. ECG abnormalities in Electrolyte Abnormalities 5. Assessment of RV function 6. Ankle Brachial Index 7. Myocardial Hibernation 8. Dynamic Auscultation 9. ECHO assessment of Restrictive Cardiomyopathy 10. Abdomino Jugular Reflux
- 80. Rajiv Gandhi University of Health Sciences D.M Degree Examination – JULY-2018 Time: Three Hours Max. Marks: 100 Marks Cardiology - PAPER – III Congenital and Rheumatic Heart Diseases QP Code: 9113 Your answers should be specific to the questions asked. Draw neat, labeled diagrams wherever necessary. Answer all questions LONG ESSAY (These questions carry 10 marks each) 10 x 10 = 100 Marks 1. Diagnosis and management of MVP with MR 2. Multisystem involvement in CCHD 3. Long term complications after TOF repair 4. Assessment of operability in shunt lesions with PH 5. Peripheral pulmonary stenosis – causes diagnosis and management 6. Paradoxical low flow low gradient AS – criteria, causes and management 7. Natural history of biscuspid AV 8. Management of Multivalvular disease 9. Follow up of a patient with mechanical prosthetic valve 10. Homograft and autograft valves * * *
- 81. Cardiology - PAPER – II Coronary Artery Disease QP Code: 9112 Your answers should be specific to the questions asked. Draw neat, labeled diagrams wherever necessary. Answer all questions LONG ESSAY (These questions carry 10 marks each) 10 x 10 = 100 Marks 1. Physiologic assessment of coronary artery stenosis 2. Coronary minovascular dysfunction and its management 3. Approach to acute chest pain 4. Clinical utility of troponins 5. Universal definitions and classifications of acute MI 6. Current status of non culprit vessel PCI acute MI 7. Indications and contraindications thrombolytic therapy 8. Antiplatelet therapy in a non ST elevation ACS 9. Natural history and risk stratification in stable angina 10. Thrombus aspiration during PCI – Current status