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ECGpedia - User contributions [en]
2024-03-29T10:44:40Z
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https://en.ecgpedia.org/index.php?title=Supraventricular_Rhythms&diff=9693
Supraventricular Rhythms
2009-11-11T10:42:46Z
<p>213.46.133.193: </p>
<hr />
<div>{{authors|<br />
|mainauthor= [[user:Drj|J.S.S.G. de Jong]]<br />
|moderator= [[user:Drj|J.S.S.G. de jong]]<br />
|supervisor= <br />
}}<br />
===Supraventricular tachycardias===<br />
{| class="wikitable" border="1" width="610px"<br />
|-<br />
| [[Image:atrial_ventricular.png|300px]]<br />
| [[image:SVT_overview.png|300px]]<br />
| [[Image:svt_algorhythm.png|300px]]<br />
|-<br />
!Arrhythmias are categorized into supraventricular and ventricular depending on their origin (below the bifurcation of the His bundle is ventricular)<br />
!An overview of pathological supraventricular arrhythmias and their origin<br />
!A algorithm to diagnose SVTs<cite>ACC</cite><br />
|}<br />
{| class="wikitable" font-size="90%"<br />
|- style="text-align:center;background-color:#6EB4EB;"<br />
|+'''An overview of supraventricular tachycardias'''<br />
|-<br />
!<br />
!example (lead II)<br />
!regularity<br />
!atrial frequency<br />
!ventricular frequency<br />
!origin (SVT/VT)<br />
!p-wave<br />
!effect of adenosine<br />
|- <br />
| colspan="8" style="text-align:left;background-color:#cfefcf;" | '''Narrow complex (QRS<0.12)'''<br />
|-<br />
! [[Sinustachycardia]]<br />
| [[Image:sinustachy_small.svg|200px|Sinustachycardia - a normal p wave precedes every QRS complex]]<br />
| regular<br />
| 100-180 bpm<br />
| 100-180 bpm<br />
| sinusnode (SVT)<br />
| precedes every QRS complex<br />
| gradual slowing<br />
|-<br />
! [[Atrial Fibrillation]]<br />
| [[Image:afib_small.svg|200px|Atrial fibrillation - irregular rate, no p waves]]<br />
| grossly irregular<br />
| 400-600 bpm <br />
| 75-175 bpm <br />
| atria (SVT)<br />
| absent<br />
| slows down rate; irregularity remains<br />
|-<br />
! [[Atrial Flutter]]<br />
| [[Image:aflutt_small.svg|200px|Atrial flutter - sawtooth in lead II with 2:1 block]]<br />
| regular (sometimes alternating block) <br />
| 250-350 bpm <br />
| 75-150 bpm (3:1 or 2:1 block is most common) <br />
| atria (SVT)<br />
| negative sawtooth in lead II <br />
| temporary reduced conduction (e.g. 4:1)<br />
|-<br />
! [[AVNRT]] <br />
| [[Image:avnrt_small.svg|200px|ANVRT - rSR' in lead V1]]<br />
| regular <br />
| 180-250 bpm<br />
| 180-250 bpm <br />
| AV-node (SVT)<br />
| in QRS complex (R') <br />
| stops<br />
|-<br />
! [[Atrial Tachycardia]]<br />
| [[Image:atrialtachy_small.svg|200px|Atrial tachycardia - like sinustachycardia but the p wave has a different morphology]]<br />
| regular<br />
| 120-250 bpm <br />
| 75-200 bpm<br />
| atria<br />
| precedes QRS, p wave differs from sinus-p <br />
| temporary AV-block<br />
|-<br />
! [[AVRT|Atrio-Ventricular Reentry Tachycardia (AVRT)- orthodromic]]<br />
| [[Image:avrt_small.svg|200px|AVRT - inverted p wave behind every QRS complex]]<br />
| regular <br />
| 150-250 bpm<br />
| 150-250 bpm<br />
| circle: av-node - ventricles - bypass - atria<br />
| RP < PR <br />
| stops<br />
|-<br />
! [[AVJT|AV junctional tachycardia]]<br />
| [[Image:avnodal_small.svg|200px|AV junctional tachycardia - no or inverted p-waves within QRS complex]]<br />
| regular <br />
| 60-100 bpm<br />
| 70-130 bpm<br />
| AV node<br />
| RP < PR <br />
| reduces rate<br />
|- <br />
| colspan="8" style="text-align:left;background-color:#cfefcf;" | '''Wide complex (QRS>0.12)'''<br />
|-<br />
! [[Supraventricular tachycardia with block]]<br />
| [[Image:atrial_tachy_with_LBBB_leadII.svg|200px|SVT with block - any SVT combined with LBBB or RBBB]]<br />
| (ir)regular depending on SVT<br />
| 100-250 bpm<br />
| 75-200 bpm<br />
| atria (SVT)<br />
| absent<br />
| temporary increased AV-block (eg 4:1)<br />
|-<br />
! [[AVRT|Atrio-ventricular Reentry Tachycardia (AVRT) - antidrome]]<br />
| <br />
| regular <br />
| 150-250 bpm<br />
| 150-250 bpm<br />
| circular: bypass - atria - av-node - ventricles<br />
| RP < PR <br />
| stops<br />
|-<br />
|}<br />
<br />
{{Box|<br />
===Supraventricular [[Ectopic Beats|ectopic beats]]===<br />
*[[Atrial Premature Complexes]]<br />
*[[Wandering Pacemaker]]<br />
*[[AV-nodal complexes]]<br />
}}<br />
{{Box|<br />
===Also read===<br />
*[[Introduction to Arrhythmias]]<br />
*[[Mechanisms of Arrhythmias]]<br />
*[[Sinus node rhythms and arrhythmias]]<br />
*[[Junctional Tachycardias]]<br />
*[[Ventricular Arrhythmias]]<br />
}}<br />
{{Box|<br />
==References==<br />
<biblio><br />
#ACC pmid=14563598<br />
</biblio><br />
}}<br />
[[Category:ECG Textbook]]</div>
213.46.133.193
https://en.ecgpedia.org/index.php?title=Ventricular_pre-excitation_(Wolff-Parkinson-White_pattern)&diff=9687
Ventricular pre-excitation (Wolff-Parkinson-White pattern)
2009-11-09T19:41:21Z
<p>213.46.133.193: /* References */</p>
<hr />
<div>[[Image:wolffparkinsonwhite.jpg|thumb| Louis Wolff, Sir John Parkinson and Paul Dudley, who discovered the phenomenon that later would be called the WPW syndrome.]]<br />
[[Image:Rhythm_WPW.png|thumb| The upstroke of the QRS-complex is 'slurred', resulting in a delta-wave (arrow).]]<br />
[[Image:WPW.png|thumb| A atrioventricular tachycardia through the accessory bundle. The electrical signal travels from the ventricles via the accessory bundle to the atria and returns to the ventricles via the AV node.]]<br />
[[Image:wpw_full_ecg.jpg|thumb| WPW on a 12 lead ECG.]]<br />
[[Image:wpw_full_ecg2.jpg|thumb| Another example of pre-exitation on a 12 lead ECG.]]<br />
[[Image:wpw_full_ecg3.png|thumb| Another example of WPW on a 12 lead ECG.]]<br />
[[Image:ECG000029.jpg|thumb| Atrial fibrillation in a patient with WPW: Fast Broad Irregular (FBI)]]<br />
[[Image:ECG000030.jpg|thumb| Same patient as above during sinus rhythm: evident delta wave]]<br />
<br />
In 1930 Louis Wolff, Sir John Parkinson and Paul Dudley White described 11 patients who suffered from bouts of tachcyardias. Their ECGs showed two abnormalities: a short PQ time and a delta-wave.<br />
Ever since one speaks of the '''Wolff-Parkinson-White syndrome''' in patients with complaints of syncope and / or tachycardia and a pre-exitation pattern on the ECG (WPW syndrome = WPW pattern + symptoms). Not all patients with a WPW ''pattern'' on the ECG are symptomatic. The prevalence of the WPW or pre-exitation pattern is relatively common in the general population (about 0.15-0.25%).<br />
<br />
The pre-exitation pattern is caused by an extra connection between the atria and the ventricles (accessory bundle) that forms an electrical bypass to the AV node. The part of the ventricle where this accessory bundle connects are the first to depolarize. This is shown on the ECG as a delta wave. The QRS-complex is somewhat widened (> 0.10 sec). Also the PQ time is shorter (< 0.12 sec). By observing the pattern of the delta wave in the different leads, one can estimate the location of the accessory bundle.<br />
<br />
The risk of having an accessory bundle is the development of tachycardias. Two forms of tachycardias exist:<br />
* An atrioventricular tachcyardia, in which the electrical signal from the ventricles is conducted back to the atria. These fast arrhythmias (> 200 bpm) can deteriorate into [[#ventricular fibrillation|ventricular fibrillation]] and sudden death.<br />
* A supraventricular tachycardia with 1:1 conduction through the accessory bundle. A typical example is atrial fibrillation. Atrial fibrillation in WPW can result in a fast and irregular tachycardia: Fast, Broad & Irregular (FBI). This fast arrhythmia also carries the risk to deteriorate into [[#ventricular fibrillation|ventricular fibrillation]] and sudden death.<br />
<br />
In clinical practice it is therefore important to distinguish '''benign''' from '''malign''' accessory bundles.<br />
<br />
'''Characteristics of a benign accessory bundle''' <br />
*Intermittant WPW pattern on [[Holter]] registration<br />
*Sudden disappearing of the pre-exitation pattern during exercise testing.<br />
*The accessory bundle responds to blockade by medication (especially sodium channel blockers)<br />
<br />
'''Characteristics of a malign accessory bundle''' <br />
*The occurence of very fast arrhythmias during spontanous attacks of atrial fibrillation (> 240 bpm).<br />
<br />
WPW can be treated by destroying the accessory bundle with ablation therapy.<cite>Pappone</cite> Depending on the type of arrhythmias that occur anti-arrhythmic therapy can play a role.<br />
{{clr}}<br />
<br />
== Determining the location of the accessory pathway ==<br />
{| class= "wikitable"<br />
|colspan = "6" align="center"| '''Check lead V1'''<br />
|-<br />
|colspan ="3"| negative delta wave in V1 = right ventricle<br />
||<br />
|colspan ="2"| positive delta wave om V1= left ventricle<br />
|-<br />
| Negative delta wave and QRS in II, III, AVF || Left axis || Inferior axis|| ||Negative delta wave and QRS in II, III, AVF || isoelectric or negative delta I, AVL, V5, V6<br />
|-<br />
| Posteroseptal || Right free wall || Anteroseptal ||||Posteroseptal || Lateral<br />
|-<br />
|}<br />
== References ==<br />
<biblio><br />
#cosio pmid=10413636<br />
#Pappone pmid=14602878<br />
#Milstein pmid=2440006<br />
</biblio></div>
213.46.133.193
https://en.ecgpedia.org/index.php?title=Main_Page&diff=9672
Main Page
2009-11-07T14:53:28Z
<p>213.46.133.193: </p>
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First read the [[Introduction]] and the [[Basics]], then follow the 7+2 step plan:<br />
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{| style="background:transparent;font-size:9pt" align="left"<br />
|-<br />
| style="background:transparent" valign="top" align="left"|<br />
* [[Normal tracing|Normal tracing]]<br />
* [[A Concise History of the ECG]]<br />
* [[Technical Problems|Technical Problems]]<br />
* [[Sinus node rhythms and arrhythmias|Sinus rhythms]]<br />
** [[Sinustachycardia]]<br />
** [[Sinusbradycardia]]<br />
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** [[Supraventricular Rhythms|supraventricular]]<br />
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** [[Genetic Arrhythmias|genetic]]<br />
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|-<br />
| style="background:transparent" valign="top" align="left"|<br />
*Learn from these [[Cases and Examples|cases and examples]]<br />
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213.46.133.193
https://en.ecgpedia.org/index.php?title=Main_Page&diff=9671
Main Page
2009-11-07T14:53:05Z
<p>213.46.133.193: </p>
<hr />
<div>__NOTOC__<br />
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<div style="font-size:162%; border:none; margin:0; padding:.1em; color:#000;">Welcome to ECGpedia,</div><br />
<div style="top:+0.2em; font-size:95%;">a free electrocardiography (ECG) course and textbook,<br /> designed for medical professionals such as cardiac care nurses and physicians.</div><br />
<div id="articlecount" style="width:100%; text-align:center; font-size:85%;">ECGpedia has received more than 250.000 visitors from 188 countries.</div><br />
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| style="width:11%; font-size:95%;" |<br />
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| style="width:11%; font-size:95%;" |<br />
* [[Frequently_Asked_Questions|FAQ]]<br />
* [http://www.cardionetworks.org/benefactors-of-the-foundation/ Benefactors]<br />
* [http://www.cardionetworks.org/contact/ecgpedia-feedback/ Contact]<br />
|}<br />
<!-- 3 boxes --><br />
<div style="padding:10px"><br />
<!-- course boxes --><br />
{| width="100%" cellspacing="5"<br />
|-<br />
| style="border:1px solid #E2ACB1;background-color:#FFF5F5;padding:5px;" width="33%" valign="top" |<br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:center;color:#000;padding:0.2em 0.4em;">The ECG Course</h2><br />
<div align="center">[[File:Course.jpg|link=|140px]]</div><br />
<div align="center" style="margin-top:15px;"><br />
<div style="font-size:10pt;font-weight:bold;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em">ECG course</div><br />
{| style="background:transparent;font-size:9pt" align="left"<br />
|-<br />
| style="background:transparent" valign="top" align="left"|<br />
First read the [[Introduction]] and the [[Basics]], then follow the 7+2 step plan:<br />
#[[Rhythm]]<br />
#[[Rate]]<br />
#[[Conduction|Conduction (PQ,QRS,QT)]]<br />
#[[Heart axis]]<br />
#[[P wave morphology]]<br />
#[[QRS morphology]]<br />
#[[ST morphology]]<br />
| valign="top" align="left"|<br />
#[[Compare_the_old_and_new_ECG|Compare with previous ECG]] <br />
#[[Conclusion]]<br />
|}<br />
<div style="clear:both"></div><br />
<div style="font-size:10pt;font-weight:bold;border-top:1px solid #E2ACB1;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em;margin-top:5px;margin-bottom:5px;">[http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf ECG reference pocket card]</div><br />
<div style="border:1px solid #ccc;padding:3px;margin-top:8px;background:white">[[File:ECG_reference_card_thumbnail.jpg|link=printing instructions|290px]]</div><div style="font-size:8pt">Download and print our '''[http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf ECG Reference Card] as PDF''' (new improved version April 2009!, read the [[printing instructions]])</div><br />
<div style="text-align:center;font-size:8pt;border-top:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em;margin-top:5px;"><br />
[http://nl.ecgpedia.org/wiki/Powerpoint_presentaties_van_ECG_cursussen Ready-made presentation files for ECG courses (in Dutch)]<br />
</div><br />
</div><br />
<!--start 2nd center box--><br />
|style="border:1px solid #E2ACB1;background-color:#FFF5F5;padding:5px;" width="33%" valign="top" |<br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:center;color:#000;padding:0.2em 0.4em;">The ECG Textbook</h2><br />
<div align="center">[[File:book.jpg|link=|140px]]</div><br />
<div align="center" style="margin-top:15px;"><br />
<div style="font-size:10pt;font-weight:bold;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em">Browse the [[Textbook|ECG Textbook]]:</div><br />
{| style="background:transparent;font-size:9pt" align="left"<br />
|-<br />
| style="background:transparent" valign="top" align="left"|<br />
* [[Normal tracing|Normal tracing]]<br />
* [[A Concise History of the ECG]]<br />
* [[Technical Problems|Technical Problems]]<br />
* [[Sinus node rhythms and arrhythmias|Sinus rhythms]]<br />
** [[Sinustachycardia]]<br />
** [[Sinusbradycardia]]<br />
* [[Arrhythmias|Arrhythmias:]]<br />
** [[Supraventricular Rhythms|supraventricular]]<br />
** [[Junctional Tachycardias|junctional]]<br />
** [[Ventricular Arrhythmias|ventricular]]<br />
** [[Genetic Arrhythmias|genetic]]<br />
** [[Ectopic Beats|ectopic beats]]<br />
* Conduction<br />
** [[AV Conduction|AV Conduction]]<br />
** [[Intraventricular Conduction|Intraventricular Conduction]]<br />
* [[Myocardial Infarction|Myocardial Infarction]]<br />
* [[Chamber Hypertrophy and Enlargment|Chamber Hypertrophy]]<br />
* [[Clinical Disorders|Clinical Disorders]]<br />
* [[Electrolyte Disorders|Electrolyte Disorders]]<br />
* [[Pacemaker|Pacemaker]]<br />
* [[ECG in Athletes]]<br />
* [[Pediatric ECGs|ECG in Children]]<br />
* [[Accuracy of computer interpretation]]<br />
* [[Special:Allpages| A-Z index]]<br />
|}<br />
</div><br />
<!--start 3nd right box--><br />
| style="border:1px solid #E2ACB1;background-color:#FFF5F5;padding:5px;" width="33%" valign="top" |<br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:center;color:#000;padding:0.2em 0.4em;">Cases and Examples</h2><br />
<div align="center">[[File:cases.jpg|link=|140px]]</div><br />
<div align="center" style="margin-top:15px;"><br />
<div style="font-size:10pt;font-weight:bold;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em">Cases:</div><br />
{| style="background:transparent;font-size:9pt" align="left"<br />
|-<br />
| style="background:transparent" valign="top" align="left"|<br />
*Learn from these [[Cases and Examples|cases and examples]]<br />
*[[Guess the Culprit]]<br />
*[[Rhythm Puzzles]] by Prof. A.A.M. Wilde, MD, PhD<br />
*[[Case reports by W.G. De Voogt%2C MD%2C PhD]]<br />
*[[Rarities]]<br />
*The ''[[De Voogt ECG Archive]]'' contains > 2000 ECGs<br />
|}<br />
<div style="clear:both"></div><br />
<div style="font-size:10pt;font-weight:bold;border-top:1px solid #E2ACB1;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em;margin-top:5px;margin-bottom:5px;">[[DV_Case_4|ECG Case of the Month]]</div><br />
<div style="padding:5px;background:white;border:1px solid #ccc;"><br />
<div align="center" style="margin-top:15px;"><br />
<div align="center">[[File:DVA0004.jpg|A slow heart beat|link=|280px]]</div><br />
[[DV_Case_4| A slow heart beat]]<br />
</div><br />
</div><br />
</div><br />
|}<br />
</div><br />
<!--end of main boxes --><br />
<!--start in other language --><br />
<div style="border:1px solid #E2ACB1;padding:4px;text-align:left;background-color:#FFF5F5;margin-top:10px"><br />
<div style="padding:15px"><br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:left;color:#000;padding:0.2em 0.4em;">'''ECGpedia in other languages'''</h2><br />
*ECGpedia is also available in [http://nl.ecgpedia.org '''Dutch''']<br />
*We are '''looking for translators''' for other languages! Please [http://www.cardionetworks.org/contact/ecgpedia-feedback/ contact us] for more information if you would like to help.<br />
</div><br />
</div><br />
<!--end in other language --><br />
<!--start popular item --><br />
<div style="border:1px solid #E2ACB1;padding:4px;text-align:left;background-color:#FFF5F5;margin-top:10px"><br />
<div style="padding:15px"><br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:left;color:#000;padding:0.2em 0.4em;">'''Popular items'''</h2><br />
{| width=100% style="background:transparent"<br />
|-<br />
| width="50%" align="left" valign="top" |<br />
*The [http://www.linkedin.com/groups?gid=1872552 LinkedIn Cardionetworks Group] is a meeting for interested users and editors.<br />
*The [http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf whole course on 1 A4 paper.]<br />
*[[LBBB|Left bundle branch block]]<br />
*Measuring the QT interval - [[Conduction#The_QT_interval|beginners]] - [[Difficult QT|advanced]]<br />
*Calculate the QTc with the [[QTc calculator]] using the QT interval and the heart rate<br />
*[[Brugada Syndrome]]<br />
*[[Aivr|Accelerated Idioventricular Rhythm]]<br />
*[[LBBB|Left Bundle Branch Block]]<br />
|<br />
{| class="wikitable" align="right" style="margin:0px;border:1px solid #a3bfb1;"<br />
|<flashow>http://nl.ecgpedia.org/images/c/cc/Heartaxis.swf|height=250px|width=100%|</flashow><br />
|-<br />
| <small>The [[Heart_axis|Heart axis simulator]], made by Bart Duineveld. '''Click and drag''' the heart axis arrow to change the axis.</small><br />
|}<br />
|}<br />
</div><br />
</div><br />
<!--end popular item --><br />
<!--start news--><br />
<div style="border:1px solid #E2ACB1;padding:4px;text-align:left;background-color:#FFF5F5;margin-top:10px;"><br />
<div style="padding:15px"><br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:left;color:#000;padding:0.2em 0.4em;">'''News & Background'''</h2><br />
{| width=100% style="background:transparent"<br />
|-<br />
| width="50%" align="left" valign="top" |<br />
*The [http://www.cardionetworks.org/timeline/ historic timeline] of the Cardionetworks Foundation shows the development<br />
*All Cardionetworks sites now run on green power from NaturEnergie AG<br />
*April 2008. Due to high traffic, all websites have been moved to a new server.<br />
*The first [[media:Normal_SR.swf|animation]] made by Bart Duineveld for ECGpedia is finished.<br />
*Give us feedback on how to improve this site: [http://www.cardionetworks.org/contact/ecgpedia-feedback/ contact / feedback form]<br />
*ECGpedia.org is part of [http://www.cardionetworks.org Cardionetworks]<br />
*Read the section with [[Frequently Asked Questions]] for more information.<br />
*[[Authors|These people]] have contributed to ECGpedia. <br />
*Also read how you can [[Contributing to ECGpedia|contribute to ECGpedia]]! <br />
*Follow the [[Timeline|development of ECGpedia]]<br />
*General [[References]]<br />
| width="50%" align="right" |<br />
<flashow>http://nl.ecgpedia.org/images/0/09/Normal_SR.swf|align=right|height=300px|width=300px</flashow><br />
|}<br />
</div><br />
</div><br />
<!--end news --><br />
<br />
[[nl:Hoofdpagina]]</div>
213.46.133.193
https://en.ecgpedia.org/index.php?title=File:DVA2206.jpg&diff=9372
File:DVA2206.jpg
2009-11-04T08:11:53Z
<p>213.46.133.193: /* Summary */</p>
<hr />
<div>== Summary ==<br />
{{Information<br />
|Description = <br />
|Category =<br />
|Source = W.G. de Voogt, MD, PhD, SLAZ, The Netherlands<br />
|Date = 2008<br />
|Author = W.G. de Voogt, MD, PhD, SLAZ, The Netherlands<br />
|Permission = {{by-nc-sa-3.0}}<br />
|other_versions = None<br />
}}</div>
213.46.133.193
https://en.ecgpedia.org/index.php?title=Main_Page&diff=9370
Main Page
2009-11-04T08:10:58Z
<p>213.46.133.193: Undo revision 9315 by 122.49.210.50 (Talk)</p>
<hr />
<div>__NOTOC__ <br />
<div style="border:1px solid #AAAAAA;padding:4px;text-align:left;"><br />
<div style="padding:15px"><div style="font-size:18pt">'''Welcome to ECGpedia'''</div>''a [[w:wiki|wiki]] electrocardiography (ECG) course and textbook designed for medical professionals such as cardiac care nurses and physicians.''</div><br />
<!-- 3 boxes --><br />
<div style="padding:10px"><br />
<!-- course boxes --><br />
{| width="100%" cellspacing="5"<br />
|-<br />
| style="border:1px solid #E2ACB1;background-color:#FFF5F5;padding:5px;" width="33%" valign="top" |<br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:center;color:#000;padding:0.2em 0.4em;">The ECG Course</h2><br />
<div align="center">[[File:Course.jpg|link=|140px]]</div><br />
<div align="center" style="margin-top:15px;"><br />
<div style="font-size:10pt;font-weight:bold;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em">ECG course</div><br />
{| style="background:transparent;font-size:9pt" align="left"<br />
|-<br />
| style="background:transparent" valign="top" align="left"|<br />
First read the [[Introduction]] and the [[Basics]], then follow the 7+2 step plan:<br />
#[[Rhythm]]<br />
#[[Rate]]<br />
#[[Conduction|Conduction (PQ,QRS,QT)]]<br />
#[[Heart axis]]<br />
#[[P wave morphology]]<br />
#[[QRS morphology]]<br />
#[[ST morphology]]<br />
| valign="top" align="left"|<br />
#[[Compare_the_old_and_new_ECG|Compare with previous ECG]] <br />
#[[Conclusion]]<br />
|}<br />
<div style="clear:both"></div><br />
<div style="font-size:10pt;font-weight:bold;border-top:1px solid #E2ACB1;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em;margin-top:5px;margin-bottom:5px;">[http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf ECG reference pocket card]</div><br />
<div style="border:1px solid #ccc;padding:3px;margin-top:8px;background:white">[[File:ECG_reference_card_thumbnail.jpg|link=printing instructions|290px]]</div><div style="font-size:8pt">Download and print our '''[http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf ECG Reference Card] as PDF''' (new improved version April 2009!, read the [[printing instructions]])</div><br />
<div style="text-align:center;font-size:8pt;border-top:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em;margin-top:5px;"><br />
[http://nl.ecgpedia.org/wiki/Powerpoint_presentaties_van_ECG_cursussen Ready-made presentation files for ECG courses (in Dutch)]<br />
</div><br />
</div><br />
<!--start 2nd center box--><br />
|style="border:1px solid #E2ACB1;background-color:#FFF5F5;padding:5px;" width="33%" valign="top" |<br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:center;color:#000;padding:0.2em 0.4em;">The ECG Textbook</h2><br />
<div align="center">[[File:book.jpg|link=|140px]]</div><br />
<div align="center" style="margin-top:15px;"><br />
<div style="font-size:10pt;font-weight:bold;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em">Browse the [[Textbook|ECG Textbook]]:</div><br />
{| style="background:transparent;font-size:9pt" align="left"<br />
|-<br />
| style="background:transparent" valign="top" align="left"|<br />
* [[Normal tracing|Normal tracing]]<br />
* [[A Concise History of the ECG]]<br />
* [[Technical Problems|Technical Problems]]<br />
* [[Sinus node rhythms and arrhythmias|Sinus rhythms]]<br />
** [[Sinustachycardia]]<br />
** [[Sinusbradycardia]]<br />
* [[Arrhythmias|Arrhythmias:]]<br />
** [[Supraventricular Rhythms|supraventricular]]<br />
** [[Junctional Tachycardias|junctional]]<br />
** [[Ventricular Arrhythmias|ventricular]]<br />
** [[Genetic Arrhythmias|genetic]]<br />
** [[Ectopic Beats|ectopic beats]]<br />
* Conduction<br />
** [[AV Conduction|AV Conduction]]<br />
** [[Intraventricular Conduction|Intraventricular Conduction]]<br />
* [[Myocardial Infarction|Myocardial Infarction]]<br />
* [[Chamber Hypertrophy and Enlargment|Chamber Hypertrophy]]<br />
* [[Clinical Disorders|Clinical Disorders]]<br />
* [[Electrolyte Disorders|Electrolyte Disorders]]<br />
* [[Pacemaker|Pacemaker]]<br />
* [[ECG in Athletes]]<br />
* [[Pediatric ECGs|ECG in Children]]<br />
* [[Accuracy of computer interpretation]]<br />
* [[Special:Allpages| A-Z index]]<br />
|}<br />
</div><br />
<!--start 3nd right box--><br />
| style="border:1px solid #E2ACB1;background-color:#FFF5F5;padding:5px;" width="33%" valign="top" |<br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:center;color:#000;padding:0.2em 0.4em;">Cases and Examples</h2><br />
<div align="center">[[File:cases.jpg|link=|140px]]</div><br />
<div align="center" style="margin-top:15px;"><br />
<div style="font-size:10pt;font-weight:bold;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em">Cases:</div><br />
{| style="background:transparent;font-size:9pt" align="left"<br />
|-<br />
| style="background:transparent" valign="top" align="left"|<br />
*Learn from these [[Cases and Examples|cases and examples]]<br />
*[[Guess the Culprit]]<br />
*[[Rhythm Puzzles]] by Prof. A.A.M. Wilde, MD, PhD<br />
*[[Case reports by W.G. De Voogt%2C MD%2C PhD]]<br />
*[[Rarities]]<br />
*The ''[[De Voogt ECG Archive]]'' contains > 2000 ECGs<br />
|}<br />
<div style="clear:both"></div><br />
<div style="font-size:10pt;font-weight:bold;border-top:1px solid #E2ACB1;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em;margin-top:5px;margin-bottom:5px;">[[DV_Case_4|ECG Case of the Month]]</div><br />
<div style="padding:5px;background:white;border:1px solid #ccc;"><br />
<div align="center" style="margin-top:15px;"><br />
<div align="center">[[File:DVA0004.jpg|A slow heart beat|link=|280px]]</div><br />
[[DV_Case_4| A slow heart beat]]<br />
</div><br />
</div><br />
</div><br />
|}<br />
</div><br />
</div><br />
<!--end of main boxes --><br />
<!--start in other language --><br />
<div style="border:1px solid #E2ACB1;padding:4px;text-align:left;background-color:#FFF5F5;margin-top:10px"><br />
<div style="padding:15px"><br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:left;color:#000;padding:0.2em 0.4em;">'''ECGpedia in other languages'''</h2><br />
*ECGpedia is also available in [http://nl.ecgpedia.org '''Dutch''']<br />
*We are '''looking for translators''' for other languages! Please [http://www.cardionetworks.org/contact/ecgpedia-feedback/ contact us] for more information if you would like to help.<br />
</div><br />
</div><br />
<!--end in other language --><br />
<!--start popular item --><br />
<div style="border:1px solid #E2ACB1;padding:4px;text-align:left;background-color:#FFF5F5;margin-top:10px"><br />
<div style="padding:15px"><br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:left;color:#000;padding:0.2em 0.4em;">'''Popular items'''</h2><br />
{| width=100% style="background:transparent"<br />
|-<br />
| width="50%" align="left" valign="top" |<br />
*The [http://www.linkedin.com/groups?gid=1872552 LinkedIn Cardionetworks Group] is a meeting for interested users and editors.<br />
*The [http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf whole course on 1 A4 paper.]<br />
*[[LBBB|Left bundle branch block]]<br />
*Measuring the QT interval - [[Conduction#The_QT_interval|beginners]] - [[Difficult QT|advanced]]<br />
*Calculate the QTc with the [[QTc calculator]] using the QT interval and the heart rate<br />
*[[Brugada Syndrome]]<br />
*[[Aivr|Accelerated Idioventricular Rhythm]]<br />
*[[LBBB|Left Bundle Branch Block]]<br />
|<br />
{| class="wikitable" align="right" style="margin:0px;border:1px solid #a3bfb1;"<br />
|<flashow>http://nl.ecgpedia.org/images/c/cc/Heartaxis.swf|height=250px|width=100%|</flashow><br />
|-<br />
| <small>The [[Heart_axis|Heart axis simulator]], made by Bart Duineveld. '''Click and drag''' the heart axis arrow to change the axis.</small><br />
|}<br />
|}<br />
</div><br />
</div><br />
<!--end popular item --><br />
<!--start news--><br />
<div style="border:1px solid #E2ACB1;padding:4px;text-align:left;background-color:#FFF5F5;margin-top:10px;"><br />
<div style="padding:15px"><br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:left;color:#000;padding:0.2em 0.4em;">'''News & Background'''</h2><br />
{| width=100% style="background:transparent"<br />
|-<br />
| width="50%" align="left" valign="top" |<br />
*The [http://www.cardionetworks.org/timeline/ historic timeline] of the Cardionetworks Foundation shows the development<br />
*All Cardionetworks sites now run on green power from NaturEnergie AG<br />
*April 2008. Due to high traffic, all websites have been moved to a new server.<br />
*The first [[media:Normal_SR.swf|animation]] made by Bart Duineveld for ECGpedia is finished.<br />
*Give us feedback on how to improve this site: [http://www.cardionetworks.org/contact/ecgpedia-feedback/ contact / feedback form]<br />
*ECGpedia.org is part of [http://www.cardionetworks.org Cardionetworks]<br />
*Read the section with [[Frequently Asked Questions]] for more information.<br />
*[[Authors|These people]] have contributed to ECGpedia. <br />
*Also read how you can [[Contributing to ECGpedia|contribute to ECGpedia]]! <br />
*Follow the [[Timeline|development of ECGpedia]]<br />
*General [[References]]<br />
| width="50%" align="right" |<br />
<flashow>http://nl.ecgpedia.org/images/0/09/Normal_SR.swf|align=right|height=300px|width=300px</flashow><br />
|}<br />
</div><br />
</div><br />
<!--end news --><br />
<br />
[[nl:Hoofdpagina]]</div>
213.46.133.193
https://en.ecgpedia.org/index.php?title=Long_QT_Syndrome&diff=9280
Long QT Syndrome
2009-09-30T19:53:04Z
<p>213.46.133.193: Undo revision 9279 by 213.182.125.231 (Talk)</p>
<hr />
<div>{{authors|<br />
|mainauthor= [[user:Drj|J.S.S.G. de Jong, MD]]<br />
|supervisor=<br />
|coauthor= [[user:Pgpostema|P.G. Postema, MD]]<br />
|moderator= [[user:Pgpostema|P.G. Postema, MD]]<br />
|editor= <br />
}}<br />
[[Image:acquired_longQT.jpg|thumb|A 12 lead ECG of a patient with acquired long QT syndrome. Notice the QT prolongation. The QTc is about 640ms.]]<br />
The '''Long QT Syndrome (LQTS)''' is characterized on the ECG by prolongation of the [[Conduction#The_QT_interval|heart rate corrected QT interval]]. This was first recognized by dr. Jervell and dr. Lange-Nielsen in 1957. They described 4 children with a long QT interval which was accompanied by hearing deficits, sudden cardiac death and an autosomal recessive inheritance.<cite>Lang1957</cite><br />
<br />
The Long QT syndrome may be divided into two distinct forms: congenital Long QT syndrome and acquired Long QT syndrome. These forms may however <br />
<br />
===Diagnosis===<br />
*The diagnosis is by maesurement of the [[Conduction#The_QT_interval|heart rate corrected QT interval]] on the ECG, which can be calculated with the [[QTc calculator]].<br />
*Sometinmes the QT interval can be difficult to assess. Read the [[Difficult_QT|guidelines for measurement of difficult QT interval]].<br />
*A QTc of > 500ms in patients with Long QT Syndrome is associated with an increased risk for sudden death.<cite>Priori</cite> <br />
*In patients suspected of LQTS (e.g. family members of known LQTS patients) a QTc > 430ms makes it likely that a LQTS gene defect is present.<cite>Hofman</cite><br />
*Because the QTc can change with age, it is best to take the ECG with the longest QTc interval for risk stratification.<cite>Goldenberg</cite><br />
<br />
===Treatment<cite>ACC2006</cite>===<br />
*"Lifestyle modification":<br />
** No competitive sports in all LQTS patients<br />
** No swimming in LQT1 patients<br />
** Avoid nightly noise in LQT2 patients (e.g. no alarm clock)<br />
*Medication: beta-blockers. Beta-blockers even reduce the risk of sudden death in patients in whom a genetic defect has been found, but no QT prolongation is visible on the ECG.<br />
*[[:w:nl:Internal_Cardiac_Defibrillator|ICD]] implantation in combination with beta-blockers in LQTS patients with previous cardiac arrest or [[syncope]] or [[Ventricular Tachycardia|ventricular tachycardia]] while on beta-blockers.<br />
<br />
===Acquired LQTS===<br />
Acquired LQTS is most often caused by drugs that prolong the QT interval. Combined with risk factors (see table) the risk of [[Torsade_de_Pointes|Torsade de Pointes]] increases.<br />
<br />
{| <br />
|-<br />
|valign="top"|<br />
{| class="wikitable" width="400px"<br />
!Common drugs that can cause [[Torsade_de_Pointes|Torsade de Pointes]] include:<cite>Roden</cite><br />
|-<br />
|<br />
<ul><br />
<li>Sotalol</li><br />
<li>Amiodarone</li><br />
<li>Erythromycin</li><br />
<li>Clarithromycin</li><br />
</ul><br />
|-<br />
!Less often used drugs include:<br />
|-<br />
|<br />
<ul><br />
<li>Cisapride</li><br />
<li>antibiotics: halofantrine, pentamidine, sparfloxacin</li><br />
<li>Anti-emetics: domperidon, droperidol</li><br />
<li>Anti-psychotics: chlorpromazine, haloperidol, mesoridazine, thioridazine, pimozide</li><br />
<li>Methadon</li><br />
<li>Disopyramide</li><br />
<li>Dofetilide</li><br />
<li>Ibutilide</li><br />
<li>Procainamide</li><br />
<li>Quinidine</li><br />
<li>Bepridil</li><br />
</ul><br />
|-<br />
|[http://www.torsades.org Torsades.org] has an extensive list of drugs that can TdP<br />
|}<br />
|valign="top"|<br />
{| class="wikitable" align="right" width="400px"<br />
!Concomittant risk factors for medication induced [[Torsade_de_Pointes|Torsade de Pointes]]:<br />
|-<br />
|<br />
<ul><br />
<li>Female sex</li><br />
<li>Hypokalemia</li><br />
<li>Bradycardia</li><br />
<li>Recent conversion of [[Atrial Fibrillation|atrial fibrillation]], especially if QT prolonging drugs were used (sotalol, amiodarone)</li><br />
<li>Cardiac decompensation</li><br />
<li>Digoxin treatment</li><br />
<li>High or overdosing or rapid infusion of a QT prolonging drug</li><br />
<li>Pre-existing QT prolongation</li><br />
<li>Congenital long QT syndrome</li><br />
</ul><br />
|}<br />
|-<br />
|}<br />
<br />
===Congenital LQTS===<br />
[[Image:lqts1-3.png|thumb|The three most common forms of LQTS can be recognized by the '''characteristic ECG abnormalities''']]: <br />
*LQT1 'early onset' broad based T wave<br />
*LQT2 small late T wave<br />
*LQT3 prolonged QT interval with 'late onset' T wave with a normal configuration<br />
In congenital LQTS the ventricular repolarisation is prolonged. '''The prevalence is about 1:3000-5000'''. <br />
<br />
More than 10 different types of congenital LQTS have been described. However, only LQTS 1-3 are relatively common.<cite>ACC2006</cite><br />
<br />
{| border="1" cellpadding="2" cellspacing="0" bordercolor="#6EB4EB" style="font-size:100%;" class="plainlinks" class="wikitable"<br />
|- style="text-align:center;background-color:#6EB4EB;"<br />
| '''Type'''<br />
| '''Chromosome'''<br />
| '''Gene'''<br />
| '''Protein'''<br />
| '''Ionchannel'''<br />
| '''Frequency<cite>priori</cite>'''<br />
| '''SCD incidence<cite>Shah2005</cite>'''<br />
| '''Inheritance'''<br />
| '''ECG characteristics'''<br />
| '''Trigger'''<br />
| '''Eponyme'''<br />
| '''[[w:OMIM|OMIM&trade;]] link'''<br />
|-<br />
! LQTS1<br />
| 11p15<br />
| KCNQ1<br />
| KvLQT1 <br />
| I''ks''<br />
| ~50%<br />
| 0.30%/year<br />
| AD, AR<br />
| broad base 'early onset' T wave<br />
| exercise, especially swimming<br />
| JLN1 if homozygous, LQTS1 if heterozygous<br />
| {{OMIM2|607542}} <br />
|-<br />
! LQTS2<br />
| 7q35<br />
| KCNH2<br />
| hERG<br />
| I''kr''<br />
| 30-40%<br />
| 0.60%/year<br />
| AD<br />
| small late T wave<br />
| adrenergic triggers, especially nightly noise<br />
| JLN2 if homozygous, LQTS2 if heterozygous<br />
| {{OMIM2|152427}}<br />
|-<br />
! LQTS3<br />
| 3p21<br />
| SCN5A<br />
| NA channel<br />
|<br />
| 5-10%<br />
| 0.56%/year<br />
| AD<br />
| 'Late onset' T wave with normal configuration<br />
|<br />
|<br />
| {{OMIM2|600163}}<br />
|-<br />
! LQTS4<br />
| 4q25-q27<br />
| ANK2<br />
| Ankyrin B<br />
| I''Na,K''<br />
| <1%<br />
| <br />
| AD<br />
|<br />
|<br />
|<br />
| {{OMIM2|106410}}<br />
|-<br />
! LQTS5<br />
| 21q22.1<br />
| KCNE1<br />
| minK <br />
| I''ks''<br />
| <1%<br />
| unknown<br />
| AD/AR<br />
|<br />
|<br />
|<br />
| {{OMIM2|176261}}<br />
|-<br />
! LQTS6<br />
| 21q22.1<br />
| KCNE2<br />
| MiRP1<br />
| I''kr''<br />
| <1%<br />
| unknown<br />
| AD<br />
|<br />
|<br />
|<br />
| {{OMIM2|603796}}<br />
|-<br />
! LQTS7 = ATS1<br />
| 17q23<br />
| KCNJ2<br />
| Kir 2.1<br />
| I''K1''<br />
| <1%<br />
| unknown<br />
| AD<br />
|<br />
|<br />
| Anderson-Tawil syndrome<br />
| {{OMIM2|600681}}<br />
|-<br />
! LQTS8 = TS1<br />
| 12p13.3<br />
| CACNA1C<br />
| Ca<sub>v</sub>1.2<br />
| I''Ca-L''<br />
| <1%<br />
| unknown<br />
| <br />
| alternating T waves<br />
|<br />
| Timothy syndrome<br />
| {{OMIM2|601005}}<br />
|-<br />
! LQTS9<br />
| 3p25.3<br />
| CAV3<br />
| Caveolin 3<br />
| I''Na''<br />
| <br />
| unknown<br />
| <br />
| <br />
|<br />
| <br />
| {{OMIM2|601253}}<br />
|-<br />
! LQTS10<br />
| 11q23.3<br />
| SCN4B<br />
| Na<sub>v</sub>1.5 b4<br />
| <br />
| 1 family<br />
| unknown<br />
| <br />
| <br />
|<br />
| <br />
| {{OMIM2|608256}}<br />
|-<br />
! LQTS11<br />
| 7q21-q22<br />
| Akap9<br />
| AKAP<br />
| I''ks''<br />
| 1 family<br />
| unknown<br />
| <br />
| <br />
|<br />
| <br />
| {{OMIM2|611820}}<br />
|}<br />
;LQTS: Long QT syndrome<br />
;JLN: Jervell and Lange-Nielsen syndrome<br />
;SCD: Sudden Cardiac Death<br />
<br />
Long before the genes involved were known, two syndromes had been described that were associated with a prolonged QT interval on the ECG.<br />
* Anton Jervell and Fred Lange-Nielsen from Oslo described in 1957 a autosomaal recessive syndrome that was associated with QT interval prolongation, deafness and sudden death: the now called '''Jervell-Lange-Nielsen syndrome'''. <cite>Lang1957</cite><br />
* '''Romano-Ward syndrome''' is a long QT syndrome with normal auditory function and autosomal dominant inheritance. <br />
* In a genotype–phenotype study by Moss et al. that studied type-1 LQTS, it was found that mutations located in the transmembrane portion of the ion channel protein and the degree of ion channel dysfunction caused by the mutations are important independent risk factors influencing the clinical course of this disorder.<cite>moss</cite><br />
<br />
==External links==<br />
#[http://www.torsades.org Torsades.org has a list of QT prolonging drugs]<br />
#[http://qtdrugs.org QTdrugs.org, another list of QT prolonging drugs]<br />
#[http://www.sads.org Sudden Arrhythmia Death Syndrome Foundation]. LQTS patient group.<br />
#[http://www.fsm.it/cardmoc/ Inherited Arrhythmias Database]<br />
<br />
==Referenties==<br />
<biblio><br />
#Schwartz2001 pmid=11136691<br />
#Shah2005 pmid=16230503<br />
#Lang1957 pmid=13435203<br />
#ACC2006 pmid=16935995<br />
#Goldenberg pmid=16949500<br />
#Roden pmid=14999113<br />
#moss pmid=17470695<br />
#priori pmid=12736279<br />
#Hofman pmid=17090615<br />
#Roden pmid=18184962<br />
</biblio></div>
213.46.133.193
https://en.ecgpedia.org/index.php?title=Chamber_Hypertrophy_and_Enlargment&diff=9269
Chamber Hypertrophy and Enlargment
2009-09-13T19:03:31Z
<p>213.46.133.193: /* Example */</p>
<hr />
<div>{{authors|<br />
|mainauthor= [[user:Drj|J.S.S.G. de Jong]]<br />
|moderator= [[user:Drj|J.S.S.G. de jong]]<br />
|supervisor= <br />
}}<br />
In hypertrophy the heart muscle is thicker. This can have different causes. Left ventricular hypertrophy results from an increase in left ventricular workload, e.g. during hypertension or aortic valve stenosis. Right ventricular hypertrophy results from an increase in right ventricular workoad, e.g. emphysema or pulmonary embolisation. <br />
These causes are fundamentally different from [[Miscellaneous#Hypertrophic_Obstructive_Cardiomyopathy|hypertrophic obstructive cardiomyopathy (HCM)]], which is a congenital misallignment of cardiomyocytes resulting in hypertrophy. <br />
<br />
Left and right ventricular hypertrophy can be distinguished on the ECG:<br />
<br />
==Left ventricular hypertrophy==<br />
[[Image:E_lvh.jpg|thumb|left|300px|LVH. R in V5 is 26mm, S in V1 in 15mm. The sum is 41 mm which is more than 35 mm and therefore LVH is present according to the Sokolow-Lyon criteria.]]<br />
[[Image:LVH.png|thumb|250px]]<br />
<br />
As the left ventricular becomes thicker, the QRS complexes become larger. This is especially true for leads V1-V6. The S wave in V1 is deep, the R wave in V4 is high. Often some ST depression can be seen in leads V5-V6, which is in this setting is called a 'strain pattern'.<br />
<br />
To diagnose left ventricular hypertrhophy on the ECG one of the following criteria should be met:<br />
The '''Sokolow-Lyon criterium'''<cite>Sokolow</cite>), this is most often used:<br />
*R in V5 or V6 + S in V1 >35 mm. <br />
<br />
Other criteria:<br />
*R >26 mm in V5 or V6; <br />
*R >20 mm in I, II or III; <br />
*R >12 mm in aVL (in the absence of [[Conduction delay#LAFB|left anterior fascicular block]]);<br />
<br />
The '''Cornell-criterium''' has different values in men and women:<br />
* R in aVL and S in V3 >28 mm in men<br />
* R in aVL and S in V3 >20 mm in women<br />
<br />
In the '''Romhilt-Estes Score''' LVH is ''likely'' with 4 or more points. LVH is ''present'' with 5 or more points:<br />
* Amplitude of R or S wave in limb leads >2.0 mV, or S wave in V1 or V2 >3.0 mV, or R wave in V5 or V6 >3.0 mV = 3 points.<br />
* ST-segment changes with or without digitalis = 1 or 2 points, respectively.<br />
* LA abnormality = 3 points.<br />
* Left-axis deviation -30° or more = 2 points.<br />
* QRS duration >90 ms = 1 point.<br />
* Intrinsicoid deflection in V5 or V6 = 0.05 to 0.07 s.<br />
<br />
Left ventricular hypertrophy has prognostic consequences as has been found in several studies.<cite>Levy</cite><cite>Sundstrom</cite><br />
{{clr}}<br />
===Example===<br />
<gallery><br />
Image:ECG000027.jpg|ECG of patient with left ventricular hypertrophy according to the Sokolow-Lyon criteria<br />
Image:Extreme_lvh2.jpg|Another example of extreme left ventricular hypertrophy in a patient with severe aortic valve stenosis.<br />
Image:extreme_lvh.jpg|ECG of a patient with LVH and subendocardial ischemia leading to positive cardiovascular markers in blood testing.<br />
</gallery><br />
{{clr}}<br />
<br />
==Right ventricular hypertrophy==<br />
[[Image:RVH.png|thumb|left]]<br />
[[Image:E_rvh.jpg|thumb|450px|Right ventricular hypertrohpy, the R wave is greater than the S wave in V1]]<br />
Right ventricular hypertrophy occurs mainly in lung disease or in congenital heart disease. <br />
The ECG shows a negative QRS complex in I (and thus a right [[heart axis]]) and a positive QRS complex in V1.<br />
<br />
*QRS duration < 120ms<br />
*Right [[heart axis]] (> 110 degrees)<br />
* Dominant R wave:<br />
** R/S ratio in V1 or V3R > 1, or R/S ratio in V5 or V6 <= 1<br />
** R wave in V1 >= 7 mm<br />
** R wave in V1 + S wave in V5 or V6 > 10.5 mm<br />
** rSR= in V1 with R'= > 10 mm<br />
** qR complex in V1<br />
* Secondary ST-T changes in right precordial leads<br />
* Right atrial abnormality<br />
* Onset of intrinsicoid deflection in V1 between 0.035 and 0.055 s<br />
<br />
{{clr}}<br />
<br />
==Left atrial enlargement==<br />
<div style="float:right;margin-left:10px"><br />
<gallery><br />
Image:left_atrial_enlargement.jpg| Left atrial enlargement<br />
Image:LAE.png| Left atrial enlargement with ECG.<br />
Image:LAE-v1.png| Left atrial enlargement as seen in lead V1.<br />
Image:LAE_12lead.jpg| Left atrial enlargement as seen on a 12 lead ECG<br />
</gallery><br />
</div><br />
;Criteria for left atrial voor left atrial enlargement. Either<br />
:P wave with a broad (>0,04 sec or 1 small square) and deeply negative (>1 mm) terminal part in V1<br />
:P wave duration >0,12 sec in laeds I and / or II<br />
Left atrial enlargement is often seen in mitral valve insufficiency, resulting in backflow of blood from the left ventricle to the left atrium and subsequent incresed local pressure. <br />
{{clr}}<br />
<br />
==Right atrial enlargement==<br />
<div style="float:right;margin-left:10px"><br />
<gallery><br />
Image:right_atrial_enlargement.jpg|Right atrial enlargement<br />
Image:RAE.png|Right atrial enlargement<br />
</gallery><br />
</div><br />
;Right atrial enlargement is defined as either:<br />
:P >2,5 mm in II / III and / or aVF <br />
:P >1,5 mm in V1.<br />
Right atrial enlargement can result from increased pressure in the pulmonary artery, e.g. after pulmonary embolisation. A positive part of the biphasic p-wave in lead V1 larger than the negative part indicates right atrial enlargement. The width of the p wave does not change. <br />
{{clr}}<br />
<br />
==Biatrial enlargement==<br />
;Biatrial enlargement<br />
:Biphasic p wave in V1 of more than 0.04 sec duration. The positive initial part is > 1.5mm and the negative terminal part > 1mm<br />
In biatrial enlargement is the ECG whos signs of both left and right atrial enlargement. In V1 the p wave has large peaks first in positive and later in negative direction.<br />
<br />
{{box|<br />
==References==<br />
<biblio><br />
#Sokolow Sokolow M, Lyon TP: ''The ventricular complex in left verntricular hypterfophy as obtained by unipolar precordial and limb leads.'' Am Heart J 37: 161, 1949<br />
#Levy pmid=11352882<br />
#Sundstrom pmid=7923663<br />
</biblio><br />
}}<br />
<br />
<br />
[[Category:ECG Textbook]]</div>
213.46.133.193
https://en.ecgpedia.org/index.php?title=Clinical_Disorders&diff=9244
Clinical Disorders
2009-09-02T16:59:09Z
<p>213.46.133.193: /* Tamponade */</p>
<hr />
<div>{{authors|<br />
|mainauthor= [[user:Vdbilt|I.A.C. van der Bilt, MD]]<br />
|moderator= [[T.T. Keller]]<br />
|supervisor=<br />
}}<br />
<br />
==Medication==<br />
===Digoxin===<br />
[[Image:med_digitalis.png|thumb|300px|Typical for digoxin intoxication is the odd shaped ST-depression]]<br />
ECG changes typical for digoxin intoxication (digoxin = Lanoxin) are:<br />
*odd shaped ST-depression. <br />
*T-wave flat, negative or biphasic<br />
*Short QT interval<br />
*Increased u-wave amplitude<br />
*Prolonged PR-interval<br />
*Brady-arrhytmias:<br />
**Sinusbradycardia<br />
**AV block. Including complete AV block and Wenkebach.<br />
*Tachyarrhythmias:<br />
**Junctional tachycardia<br />
**Atrialtachycardia<br />
**Ventricular ectopia, bigemini, monomorphic ventricular tachycardia, bidirectional ventricular tachycardia<br />
<br />
Intoxication can lead to a SA-block or AV-block, sometimes in combination with a tachycardia. '''NB''' these effects are increased by hypokaliemia. In extreme high concentrations rhythmdisturbances (''ventricular tachycardia, ventricular fibrillation, atrial fibrillation'') may develop.<br />
{{clr}}<br />
===Anti-arhythmics===<br />
* '''anti-arhythmics:''' These may lead to several ECG-changes;<br />
**broad and irregulair P-wave<br />
**broad QRS-complex<br />
**prolonged QT-interval (brady-, tachycardia, AV-block, ventricular tachycardia)<br />
**prominent U-wave<br />
**In case of intoxication, the above mentioned characteristics are more prominent<br />
<br />
Additionally, several arrhtythmias can be seen.<br />
<br />
=== Nortriptyline intoxication ===<br />
<div align="center"><br />
{|<br />
|<br />
[[Image:ECG_nortr_intox.png|thumb|left|300px|An example of severe nortriptyline intoxication. The inhibitory effect of the sodiumchannel manifests as a broadened QRS complex and a prolonged QT interval.]]<br />
|<br />
[[Image:ECG_TCA_intox.jpg|thumb|left|300px| Another example of severe nortriptyline intoxication.]]<br />
{{clr}}<br />
|}<br />
</div><br />
=== Amitriptyline intoxication ===<br />
<div align="center"><br />
{|<br />
|<br />
[[Image:ECG_amitr_OD_during.jpg|thumb|300px| An example of a severe amitriptylin intoxication. The inhibitory effect of the sodiumchannel manifests as a broadened QRS complex.]]<br />
|<br />
[[Image:ECG_amitr_OD_before.jpg|thumb|300px| An ECG of the same patient before the intoxication.]]<br />
|}<br />
</div><br />
{{clr}}<br />
<br />
==Pericarditis==<br />
[[Pericarditis]]<br />
<br />
==Myocarditis==<br />
<br />
[[w:Myocarditis|Myocarditis]] is an inflammation of the myocardium and the interstitium. The symptoms are faint chestpain, abnormal heartrate and progressive heartfailure. It can be caused by several factors: viral, bacterial, fungi, parasites, spirochaet, auto-immune, borreliosis (Lyme's disease) and HIV/AIDS. <br />
<br />
Acute peri/myocarditis causes aspecific ST changes. These can be accompanied with supraventricular and ventricular rhythmdisturbances and T-wave abnormalities.<br />
<br />
==Pulmonary embolism==<br />
See the chapter [[Pulmonary Embolism]]<br />
<br />
==Chronic pulmonary disease pattern==<br />
The ECG shows low voltaged QRS-complexes in leads I, II, and III and a right axisdeviation. This is caused by the increased pressure on the right chamber. This leads to right ventricular hypertrophy.<br />
<br />
==Pacemaker==<br />
See the chapter [[Pacemaker]]<br />
<br />
==Tamponade==<br />
[[Image:PulsusAlternans.jpg|thumb|Electrical alternans on the ECG]]<br />
In case of a tamponade, fluid collects in the pericardium. As the pericardium is stiff, the heart is compressed resulting in relaxation, and thus, filling difficulties. This is a potential life-threatening situation and should be treated with pericardiocenteses, which is drainage of the fluid. Tamponade can be the results of pericarditis or myocarditis. Also, after a myocardial infarction a tamponade may develop, this is called Dresslers' Syndrome. In case of cancer, pericardial fluid may develop. This is usually caused by a Pericarditis carcinomatosa, meaning that the cancer has spread to the pericardium<br />
<br />
The ECG shows:<br />
*Sinus tachycardia<br />
*Low-voltaged QRS complexes [[microvoltages]]<br />
*Alternation of the QRS complexes, usually in a 2:1 ratio. Electrical alternans can also be seen in myocardial ischemia, acute pulmonary embolism, and tachyarrhythmias<br />
*PR segment depression (this can also be observed in an [[Ischemia#Atriaal_.2F_boezem_infarct|atrial infarction]])<br />
{{clr}}<br />
<br />
==Ventricular Aneurysm==<br />
The ECG pattern suggests an acute MI. All classical signs of MI may occur:; Q-waves, ST-elevations (>1mm, >4 weeks present)and T-wave inversions are present. To exclude an acute MI, comparison with old ECG's is compulsory (MI has occurred years before).<br />
<br />
==Dilated Cardiomyopathy==<br />
Often, a LBBB or broadened QRS-complex can be seen. Additionally, aspecific ST changes are present with signs of left atrial enlargement.<br />
<br />
==Hypertrophic Obstructive Cardiomyopathy==<br />
A HOCM is an heditary illness.<br />
On the ECG there are signs of [[hypertrophy|left ventricular hypertrophy]] and [[P wave morphology|left atrial enlargement]].<br />
<br />
==Electrolyte disturbances==<br />
See chapter: [[electrolyte disturbances]]<br />
<br />
==Hypothermia==<br />
[[Image:osborne.png|thumb|left|250px| An Osborne J wave]]<br />
<div style="float:right"><br />
<gallery><br />
Image:osborne_ecg.jpg|A 12 lead ECG of a patient with a body temperature of 32 degrees Celsius. Note the sinusbradycardia, the prolonged QT interval (QTc is not prolonged) and the Osborne J wave, most prominantly in leads V2-V5<br />
Image:JJ0001.jpg|An ECG of a patient with a body temperature of 28 degrees Celsius.<br />
</gallery><br />
</div><br />
In hypothermia a number of specific changes can be seen;<cite>hypoth</cite><br />
* sinubradycardia<br />
* prolonged QTc-interval<br />
* ST-elevation (inferior and left precordial leads)<br />
* Osborne-waves (slow deflexions at the end of the QRS-complex)<br />
<br />
{{clr}}<br />
<br />
==ECG changes after neurologic events==<br />
[[Image:ECG_SAB.png|thumb| ECG of a 74 year old patient with a subarachnoid hemorrhage. Note the negative T-waves and the prolonged QT interval.]]<br />
In 1938, Aschenbrenner <cite>Aschenbrenner</cite> noted that repolarisation abnormalities may occur after increased intracranial pressure. Since then, many publications have occurred discribing ECG changes after acute neurological events.<br />
<br />
De ECG changes that may occur are: <br />
*q-waves<br />
*ST-elevations, <br />
*ST-depressions, <br />
*T-wave changes. Large negative T waves over the precordial leads are observed frequently.<br />
*prolonged QT-interval.<br />
*prominent u-waves.<br />
<br />
These abnormalites are frequently seen after [[w:Subarachnoid_hemorrhage|subarachnoid_hemorrhage (SAH)]] (if measured serially, almost every SAH patients has at least one abnormal ECG.), but also in [[w:Subdural_haematoma|subdural haematoma]], ischemic [[w:Cerebrovascular_accident|CVA]]'s, [[w:Brain_tumor|brain Tumors]], [[w:Guillain-Barre|Guillain Barré]], [[w:Epilepsy|epilepsy]] and [[w:Migraine|migraine]]. The ECG changes are generally reversible and have linited prognostic value. However, the ECG changes can be accompanied with myocardial damage and echocardiographic changes. The cause of the ECG changes is not yet clear. The most common hypothesis is that of a neurotramittor "catecholaminestorm" caused by sympathtic stimulation.<br />
<br />
==Cardiac contusion==<br />
Cardiac contusion (in latin: contusio cordis or commotio cordis) is caused by a blunt trauma to the chest, often caused by a car- or motorbikeaccident or in martial arts<cite>Maron</cite>. Rhythmdisturbances may occur and even heartfailure. Diagnosis is made using echocardiography and laboratorytesting for cardiac enzymes. <br />
Possible ECG changes are:<cite>Sybrandy</cite><br />
<br />
'''Not-specific changes'''<br />
*Pericarditis-like ST elevation or PTa depression<br />
*Prolonged QT interval<br />
'''Myocardial damage'''<br />
*New Q waves<br />
*ST-T segment elevation or depression<br />
'''Conduction delay'''<br />
*Right bundelbranchblok<br />
*Fascicular blok<br />
*AV delay(1st, 2nd, and 3rd degree AV blok)<br />
'''Arrhythmias'''<br />
*Sinustachycardia<br />
*Atrial and ventricular extrasystoles<br />
*Atrial fibrillation<br />
*Ventricular tachycardia<br />
*[[Arrhythmias#Ventricular fibrillation|Ventricular fibrillation]]<br />
*Sinusbradycardia<br />
*Atriala tachycardia<br />
<br />
==Lown Ganong Levine Syndrome==<br />
The Lown Ganong Levine Syndrome is a pre-excitation syndrome in which the atria are connected to the lower part of the AV node or bundle of His. On the ECG:<br />
* short PR interval, < 120 ms<br />
* normal QRS complex<br />
* no delta wave<br />
==Left and right bundelbranch block==<br />
See: [[Conduction_delay|Conduction delay]]<br />
<br />
<br />
==Cocaine Intoxication==<br />
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{{Box|<br />
==References==<br />
<biblio><br />
#Sybrandy pmid=12695446<br />
#Rodger pmid=11018210<br />
#Ferrari pmid=9118684<br />
#Aschenbrenner Aschenbrenner R, Bodechtel G, ''Ãber Ekg.-Veränderungen bei Hirntumorkranken''. Journal of Molecular Medicine, 17, 9, 2/1/1938, Pages 298-302, http://dx.doi.org/10.1007/BF01778563<br />
#Maron pmid=14681516<br />
#hypoth pmid=2738372<br />
</biblio><br />
}}<br />
[[Category:ECG Textbook]]</div>
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