Cases and Examples

Below you can find some common examples. ECGs can be magnified by clicking on the image....

Ischemia & Myocardial Infarction

An overview of the coronary arteries. LM = 'Left Main' = mainstem; LAD = 'Left Anterior Descending' artery; RCX = Ramus Circumflexus; RCA = 'Right Coronary Artery'.

Guess the culprit coronary artery that was occluded in these examples of myocardial infarctions

Examples of Myocardial Infarctions

MI 1 Where is this myocardial infarction located? Go to case Case provided by	MI 2 Where is this myocardial infarction located? Go to case Case provided by	MI 3 Where is this myocardial infarction located? Go to case Case provided by
MI 4 Where is this myocardial infarction located? Go to case Case provided by	MI 5 Where is this myocardial infarction located? Go to case Case provided by	MI 6 Where is this myocardial infarction located? Go to case Case provided by
MI 7 Where is this myocardial infarction located? Go to case Case provided by	MI 8 Where is this myocardial infarction located? Go to case Case provided by	MI 9 Where is this myocardial infarction located? Go to case Case provided by
MI 10 Where is this myocardial infarction located? Go to case Case provided by	MI 11 Where is this myocardial infarction located? Go to case Case provided by	MI 12 Where is this myocardial infarction located? Go to case Case provided by
MI 13 Where is this myocardial infarction located? Go to case Case provided by	MI 14 Where is this myocardial infarction located? Go to case Case provided by	MI 15 Where is this myocardial infarction located? Go to case Case provided by
MI 16 Where is this myocardial infarction located? Go to case Case provided by C.J. Royaards, MD	MI 17 Where is this myocardial infarction located? Go to case Case provided by C.J. Royaards, MD	MI 18 Where is this myocardial infarction located? Go to case Case provided by C.J. Royaards, MD
MI 19 Where is this myocardial infarction located? Go to case Case provided by C.J. Royaards, MD	MI 20 Where is this myocardial infarction located? Go to case Case provided by C.J. Royaards, MD	MI 21 Where is this myocardial infarction located? Go to case Case provided by C.J. Royaards, MD
MI 22 Where is this myocardial infarction located? Go to case Case provided by C.J. Royaards, MD	MI 23 Where is this myocardial infarction located? Go to case Case provided by C.J. Royaards, MD

Arrhythmias Cases

Case 1 A 45 year old female presents at the first heart aid with chest complaints... Go to case Case provided by Kees-Jan Royaards, MD	Case 2 Wide complex tachycardia: ventricular or supraventricular? ... Go to case Case provided by Kees-Jan Royaards, MD	Case 3 Myocardial infarction or not? ... Go to case Case provided by Kees-Jan Royaards, MD
Case 4 Conduction trouble ... Go to case Case provided by Kees-Jan Royaards, MD	Case 5 Sinus rhythm or not? ... Go to case Case provided by JSSG de Jong, MD	Example 26 A patient presented with a broad complex tachycardia... Go to case Case provided by

Electrolyte Disorders

Case 100 Try to interprete this ECG using the 7+2 step method Look at the consecutive ECGs in this patient. Go to case Case provided by C.J. Royaards, MD

Case 101 Look at the consecutive ECGs in this patient. What electrolyte disturbance do you expect? Go to case Case provided by C.J. Royaards, MD

Miscellaneous

Click on the text below the ECG for the answers. Click on the ECG for enlargement of the ECG itself...

Example 23 Go to case Case provided by

Example 24 Typical Brugada syndrome ST segments in right precordial ECG leads (on spot diagnosis) aka 'type-1 Brugada ECG' with 1st degree AV block and broad P-waves. Go to case Case provided by W.G. de Voogt, MD, PhD

Example 25 A regular small-QRS tachycardia at about 300bpm with normal looking QRS complexes is most likely an Atrial flutter with 1:1 conduction over the AV node. Go to case Case provided by W.G. de Voogt, MD, PhD

Rhythm Puzzles by Prof. A.A.M. Wilde

An Unexpected Narrow QRS Complex A 95-year-old woman presents with palpitations. She has no relevant medical history and the present complaint is several days old... Go to case Case provided by A.A.M. Wilde

An Irregular Heart Beat A 71-year-old female patient presents to your outpatients clinic with an irregular heart rhythm. The complaints started a few weeks ago and seem to worsen... Go to case Case provided by A.A.M. Wilde

Syncope in an Old Lady An 83-old-female patient presents to your outpatient clinic with a history of syncope. It has occurred three times in the last few months and there were no specific triggers... Go to case Case provided by A.A.M. Wilde

Wide QRS Complexes in the Setting of Acute Myocardial Infarction: Good News or Bad? A 57-year-old man collapsed after one hour of angina symptoms in the presence of the alarmed ambulance personnel. He had never had any complaints... Go to case Case provided by N.J.W. Verouden, R.J. de Winter, A.A.M. Wilde	Just an Ordinary Flutter? A 44-year-old male presented with palpitations. His medical history was otherwise uneventful and the family history revealed pacemaker... Go to case Case provided by A.A.M. Wilde, J. Hrudova, J.G.M. Tans	Wide Complexes Intervening Regular Sinus Rhythm - 3 A 73-year-old man presents with palpitations (irregular heartbeat). There is no medical history. Physical examination reveals no abnormalities... Go to case Case provided by A.A.M. Wilde
Wide Complexes Intervening Regular Sinus Rhythm - 4 A 55-year-old male without cardiac history is complaining of an irregular heartbeat. Physical examination and an echo reveal no abnormalities... Go to case Case provided by A.A.M. Wilde	The ECG of a Cardiomyopathy - 2 A 36-year-old male comes to your outpatient clinic because of his family history. His father died suddenly at age 43 and his brother died suddenly at age 39... Go to case Case provided by A.A.M. Wilde

Wide Complexes Intervening Regular Sinus Rhythm - 2 A 38-year-old male patient presents with palpitations. He is not suffering from syncope or dizziness and has no other complaints... Go to case Case provided by A.A.M. Wilde	Palpitations after a MAZE Procedure A 75-year-old lady presented with palpitations. Her medical history reveals cardiac surgery with a mitral valve repair combined... Go to case Case provided by A.A.M. Wilde, H.H.D. Idzerda	Abnormal Repolarization, Spot Diagnosis? A boy with a birth weight of 3.030 g was born by caesarean section at 33 weeks of gestation because of bradycardia and severe... Go to case Case provided by A.A.M. Wilde, N.A. Blom
An Irregular Rhythm at Older Age An 86-year-old man presents in your outpatient clinic with stable angina pectoris (NYHA 2/4). There is no further medical history... Go to case Case provided by A.A.M. Wilde	Palpitations all the Time A 14-year-old girl complained of palpitations that occurred numerous times a week. There were no special triggers and, usually... Go to case Case provided by A.A.M. Wilde, M. Cuppen, J.L.R.M. Smeets	Five Years of Palpitations A 43-year-old man came to the outpatient clinic for preventive cardiovascular (CV) screening. During the last five years he... Go to case Case provided by N.M. Panhuyzen-Goedkoop, L.R.C. Dekker, A.A.M. Wilde
An Abnormal ECG? A 47-year-old lady presents with an ‘abnormal ECG’. In her family three daughters suffer from a long-QT syndrome type 2... Go to case Case provided by A.A.M. Wilde

Right You Are A 63-year-old female was referred to our outpatient clinic with symptoms of palpitations. These had been occurring in paroxysms... Go to case Case provided by T.A. Simmers, A.A.M. Wilde	Should I be Worried? A 34-year old man comes to your office. He has read in a newspaper about the familial occurrence of sudden death. He suffered a... Go to case Case provided by A.A.M. Wilde, H.L. Tan	A Pre-excited Wide QRS Complex: is That all There is? A 28-year-old male was referred because of an abnormal ECG. He was having occasional palpitations. His family history is unremarkable... Go to case Case provided by A.A.M. Wilde, L.R.C. Dekker
An Old Lady with Chest Pain A 90-year-old lady presented with chest pain which had a sudden onset in the middle of the night. There were no other symptoms... Go to case Case provided by A.A.M. Wilde	Palpitations and Dizziness in a 65-Year-Old-Man A 65-year-old male presented with palpitations and dizziness of sudden onset, without any associated chest pain or other symptoms... Go to case Case provided by A.A.M. Wilde	A Narrow QRS Complex Tachycardia Sensitive to Isoptin A 54-year-old man presented with palpitations. He had no other symptoms. Physical examination revealed, with the exception of a... Go to case Case provided by A.A.M. Wilde, R.H. Bakker
And What About the ECG? A 63-year-old lady presented with episodic chest pain without specific triggers (in particular no relation with exercise)... Go to case Case provided by A.A.M. Wilde, R.H.J. Peters	Palpitations Again, Have a Closer Look An otherwise healthy 57-year-old lady presented with palpitations without dizziness. The symptoms had been present for a couple... Go to case Case provided by A.A.M. Wilde, L.R.C. Dekker	Wide Complexes Intervening Regular Sinus Rhythm A 28-year-old, wheelchair bound, female patient with Friedreich’s ataxia presents with an irregular heartbeat... Go to case Case provided by A.A.M. Wilde

ECG puzzle: Appearances Can be Deceiving A 61-year-old male was referred with symtoms of exertional dyspnoea and palpitations. He had suffered an anterior myocardial... Go to case Case provided by T.A. Simmers	Where Do the Extras Come From? A 64-year-old man had an inferior myocardial infarction ten years ago. Lately he has been having palpitations with occasional dizziness... Go to case Case provided by A.A.M. Wilde, R.B.A. van den Brink	The Turtle and the Hare An otherwise healthy 32-year-old male was referred with palpitations. Attacks had been occurring monthly for several years... Go to case Case provided by A.A.M. Wilde, R.B.A. van den Brink
Now You See it, Now You Don't An otherwise healthy 66-year-old male was referred with complaints of central chest pain. He was not on any medication... Go to case Case provided by T.A. Simmers, A.A.M. Wilde	It's Not What You Think it Is A 20-year-old male is having palpitations. They occur without a specific trigger, although episodes are sometimes related to... Go to case Case provided by A.A.M. Wilde, R.B.A. van den Brink	One is Enough, Two is Too Many An otherwise healthy 24-year-old man was referred to our hospital because of drug refractory spells of palpitations accompanied by dizziness... Go to case Case provided by A.A.M. Wilde, R.B.A. van den Brink
The ECG of a (Cardio)myopathy? A 33-year-old lady visited the cardiologist because of the sudden death of her brother at age 35. He died while watching TV... Go to case Case provided by A.A.M. Wilde, Y.M. Pinto	The Ions Have It A 46-year-old male was admitted to our emergency room with dyspnoea. His medical history included congestive heart failure with a left ventricular ejection Go to case Case provided by T.A. Simmers, A.A.M. Wilde

A fainting lady with some extrasystoles A 30-year-old woman presents with repeated syncope. Her symptoms started a few months ago without a particular trigger... Go to case Case provided by A.A.M. Wilde and H. Tan	Syncopated Rhythm A 65-year-old woman was admitted because of recurrent syncope. Her complaints were difficult to interpret due to mental... Go to case Case provided by L.R.C. Dekker, R. Tukkie	An Irregular Rhythm at Older Age An 86-year-old man presents in your outpatient clinic with stable angina pectoris (NYHA 2/4). There is no further medical history... Go to case Case provided by A.A.M. Wilde
I Think a Niece of Mine was Referred to a Neurologist In the setting of family screening, an 84-year-old lady was invited for a cardiogenetic evaluation. Two of her grandchildren... Go to case Case provided by A.A.M. Wilde, T.A. Simmers	Just One Collapse During Soccer A 14-year-old boy died suddenly while playing soccer. He was in the middle of a sprint when he suddenly succumbed... Go to case Case provided by A.A.M. Wilde, T.A. Simmers	Tachycardia Terminated by Adenosine A 27-year-old female was referred to the emergency room with rapid palpitations... Go to case Case provided by I.C.D. Westendorp, G.S. de Ruiter, L.V.A. Boersma, E.F.D. Wever
Nightly Phenomena, Day Time Work? In 2002, an a trial demand inhibited (AAI) pacemaker was implanted in a young male (born 1984) because of a primary arrhythmia disorder. Go to case Case provided by R. Tukkie, R. Rienks, A.A.M. Wilde

Case reports by W.G. De Voogt, MD, PhD

Case: what kind of block? This Holter registration shows pauses. Go to case Case provided by W.G. De Voogt, MD, PhD	Case: a slow heart rate This ECG shows pauses in the heart rhythm. Go to case Case provided by W.G. De Voogt, MD, PhD	Case: a pause in the heart rate This tracing shows a pause in the heart rhythm. Go to case Case provided by W.G. De Voogt, MD, PhD
Case: fever with arrhythmias This is a tracing of a 52 year old male, with viral infection and high fever (40° C), who was admitted to the... Go to case Case provided by W.G. De Voogt, MD, PhD

Case reports from the ICBA

Fusion beats Sinus bradycardia, Second degree 2:1 AV block with LBBB in the conducted beats and junctional escape beats with RBBB morphology and fusion beats that mimic normal intraventricular conduction. Go to case Case provided by Dr. Alberto Giniger	LBBB and RBBB Sinus rythm, 2:1 AV block with RBBB in the left part of the EKG and after a 1:1 conducted beat with LBBB the 2:1 AV block continues with LBBB. So it is a bilateral branch block. Go to case Case provided by Dr. Alberto Giniger	Fusion beats Sinus rythm, high degree AV block, conducted beats with RBBB and ventricular escape beats with LBBB image. Some fusion beats mimic no intraventricular disturbance confundinc as normal conducted beats. Go to case Case provided by Dr. Alberto Giniger
Escape beats Sinus rythm, high degree AV block with unional escape beats and capture beats with RBBB. Go to case Case provided by Dr. Alberto Giniger	Orthodromic tachycardia in WPW AV orthodromic tachycardia (WPW syndrome). Go to case Case provided by Dr. Alberto Giniger	Ventricular tachcyardia Ventricular tachycardia or idioventricular rythm during sinus tachycardia with fusion beats. Go to case Case provided by Dr. Alberto Giniger
Escape rhythm with RBBB pattern Go to case Case provided by Dr. Alberto Giniger	Escape rhythm with LBBB pattern Escape rhythm with left bundle branch block pattern and likely retrograde conducted P waves. Go to case Case provided by Dr. Alberto Giniger	Intermittent pre-exitation Intermittent pre-exitation Go to case Case provided by Dr. Alberto Giniger
Sinus irregularity SA exit block Go to case Case provided by Dr. Alberto Giniger	Complete AV block and left ventricle escape Complete AV block and left ventricle escape. Go to case Case provided by Dr. Alberto Giniger	Idionodal escape rythm and ventricular capture by AV nodal reentry Idionodal escape rythm and ventricular capture by AV nodal reentry... Go to case Case provided by Dr. Alberto Giniger
Idioventricular rythm with 1:1 V-A conduction Idioventricular rythm with 1:1 V-A conduction. Go to case Case provided by Dr. Alberto Giniger	Mobitz II AV block with LBBB in the conducted beats Mobitz II AV block with LBBB in the conducted beats. Go to case Case provided by Dr. Alberto Giniger	Idioventricular accelerated rythm with fusion beats Idioventricular accelerated rythm with fusion beats. Go to case Case provided by Dr. Alberto Giniger
AV nodal reentry tachycardia AV nodal reentry tachycardia. Also look at the below ladder diagram. Go to case Case provided by Dr. Alberto Giniger	3:1 AV block with idionodal escape (the third P wave is inside the QRS) AV block with idionodal escape (the third P wave is inside the QRS). Go to case Case provided by Dr. Alberto Giniger	Sinus bradicardia and isorythmic nodal escapes Sinus bradicardia and isorythmic nodal escapes. Go to case Case provided by Dr. Alberto Giniger
Coarse atrial fibrillation mimic atrial flutter Coarse atrial fibrillation mimic atrial flutter. Go to case Case provided by Dr. Alberto Giniger	Long QT and VPB secondary to sotalol administration Long QT and VPB secondary to sotalol administration Go to case Case provided by Dr. Alberto Giniger	Intermittent WPW Intermittent WPW Go to case Case provided by Dr. Alberto Giniger