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POPULAR CARDIOLOGISTS IN SAHAKARANAGAR Left ventricular hypertrophy Although the ECG is reasonably specific, it is not as sensitive as echocardiography in detecting LVH. The LVH voltage alone may be a normal finding in younger subjects, but in adults over 35 years it usually connotes true LVH, especially if corroboratory findings are present Unfortunately, LVH with ST/T changes may be impossible to separate from LVH voltage complicated by ST/T changes of different, especially ischaemic, origin . Right ventricular hypertrophy The main criteria fSAor detecting RVH are RAD over +110° and a dominant R wave in V1 (in the absence of its other causes and in the presence of normal-duration QRS) In congenital heart disease conduction defects often come to obscure the hypertrophy patterns.
the best cardiologists in yelahanka new town bangalore Miscellaneous conditions Chamber hypertrophy Left ventricular hypertrophy Although the ECG is reasonably specific, it is not as sensitive as echocardiography in detecting LVH. The LVH voltage alone may be a normal finding in younger subjects, but in adults over 35 years it usually connotes true LVH, especially if corroboratory findings are present ) Unfortunately, LVH with ST/T changes may be impossible to separate from LVH voltage complicated by ST/T changes of different, especially ischaemic, origin . Right ventricular hypertrophy The main criteria for detecting RVH are RAD over +110° and a dominant R wave in V1 (in the absence of its other causes and in the presence of normal-duration QRS) . In congenital heart disease conduction defects often come to obscure the hypertrophy patterns. An atrial (AAI) pacemaker in a patient with anterior myocardial infarction of uncertain age. There is sensing (inhibition) only after some native or paced P waves. The pacemaker captures the atria whenever the latter are not refractory: there is no failure to pace. The middle capture beat is earlier than the other two and has a longer PR interval and aberrant RBBB-type ventricular conduction. This is a pacemaker sensing problem. Reprogramming may enable the pacemaker to sense a smaller atrial amplitude and be inhibited correctly. A DDD pacemaker in trouble: there is no atrial capture and the ventricular complexes are capturing the atria on their own. The retrograde P wave interrupts the T wave and triggers another paced QRS whose retrograde conduction is blocked by the original retrograde P wave. Were it not for this block, an endless loop re-entry (paced) tachycardia would occur. The paced complexes have the typical LBBB/left-axis deviation expected from right ventricular apical pacing. Failure to capture may mean the lead has been displaced or that scarring has developed between the tip of the lead and the myocardium. Sometimes, reprogramming an increase in the output of the pacemaker will fix the problem. a = atrial pacing spike (not followed by a P wave); b = ventricular pacing spike (produced after the atrial spike after a programmed AV delay and followed by a paced ventricular beat); c = retrograde P wave following ventricular paced beat; d = pause caused by blocked retrograde conduction of the previo A DDD or VDD pacemaker with intermittent failure to pace. A 4:3 pacemakerventricular block results in trigeminy even though normal sinus rhythm continues throughout. The normal
the best cardiologists in yelahanka new town bangalore Miscellaneous conditions Chamber hypertrophy Left ventricular hypertrophy Although the ECG is reasonably specific, it is not as sensitive as echocardiography in detecting LVH. The LVH voltage alone may be a normal finding in younger subjects, but in adults over 35 years it usually connotes true LVH, especially if corroboratory findings are present ) Unfortunately, LVH with ST/T changes may be impossible to separate from LVH voltage complicated by ST/T changes of different, especially ischaemic, origin . Right ventricular hypertrophy The main criteria for detecting RVH are RAD over +110° and a dominant R wave in V1 (in the absence of its other causes and in the presence of normal-duration QRS) . In congenital heart disease conduction defects often come to obscure the hypertrophy patterns. An atrial (AAI) pacemaker in a patient with anterior myocardial infarction of uncertain age. There is sensing (inhibition) only after some native or paced P waves. The pacemaker captures the atria whenever the latter are not refractory: there is no failure to pace. The middle capture beat is earlier than the other two and has a longer PR interval and aberrant RBBB-type ventricular conduction. This is a pacemaker sensing problem. Reprogramming may enable the pacemaker to sense a smaller atrial amplitude and be inhibited correctly. A DDD pacemaker in trouble: there is no atrial capture and the ventricular complexes are capturing the atria on their own. The retrograde P wave interrupts the T wave and triggers another paced QRS whose retrograde conduction is blocked by the original retrograde P wave. Were it not for this block, an endless loop re-entry (paced) tachycardia would occur. The paced complexes have the typical LBBB/left-axis deviation expected from right ventricular apical pacing. Failure to capture may mean the lead has been displaced or that scarring has developed between the tip of the lead and the myocardium. Sometimes, reprogramming an increase in the output of the pacemaker will fix the problem. a = atrial pacing spike (not followed by a P wave); b = ventricular pacing spike (produced after the atrial spike after a programmed AV delay and followed by a paced ventricular beat); c = retrograde P wave following ventricular paced beat; d = pause caused by blocked retrograde conduction of the previo A DDD or VDD pacemaker with intermittent failure to pace. A 4:3 pacemakerventricular block results in trigeminy even though normal sinus rhythm continues throughout. The normal
Cardiologist in Chikkajala, Bangalore • Electronic pacemakers Pacemakers come as temporary or permanent, fixed-rate (although only if they are faulty these days), demand or rate-responsive, atrial, ventricular, biventricular or dual chamber, unipolar or bipolar and as a combination of many of these features. In routine ECG reporting the pacemaker’s exact programming is not usually known, but it is still possible to diagnose the pacemaker type Acute inferolateral infarction with LBBB. Although ST elevation and depression in the limb leads are suggestive, the more discrete elevation in V6 proves the diagnosis (arrows). Within hours, it disappeared and all that was left were primary T wave changes in the inferior leads ). The same patient as in , showing residual primary T wave changes in the inferior leads 90 PRACTICAL CARDIOLOGY Pathological Q waves in all the LV leads in a 90-year-old man with known old anterior infarction Table 3.1 The North American Society of Pacing and Electrophysiology (NASPE) and the British Pacing and Electrophysiology Group (BPEG) generic (NBG) pacemaker codes Position I II III IV V Category Chamber(s) paced Chamber(s) sensed Response to sensing Programmability, rate modulation Anti- tachyarrhythmia function(s) O = none A = atrium V = ventricle D = dual (A + V) O = none A = atrium V = ventricle D = dual (A + V) O = none T = triggered I = inhibited D = dual (D + I) O = none P = simple programmable M = multiprogrammable C = communicating R = rate modulation O = none P = pacing (antitachyarrhythmia) S = shock D = dual (P + S) Manufacturers’ designation only S = single (A or V) S = single (A or V) Note: positions I–III are used exclusively for anti-bradyarrhythmia function. Source: and the all-important capacity to sense the native complexes and pace the appropriate chambers. An international letter code has evolved for describing pacemaker types, shown in Table 3.1. Thus: n VVI = ventricular pacing and sensing, inhibition (in response to sensing)—the pacemaker is inhibited and produces no impulse when it senses a ventricular impulse n AAI = atrial pacing and sensing 3• AN OVERVIEW OF CLINICAL ELECTROCARDIOGRAPHY 91 n VOO = fixed-rate (asynchronous) ventricular pacing, no sensing—this is used for pacemaker testing and is the usual response of a pacemaker when a magnet is placed over it; modern pacemakers are always demand (inhibited) devices n DDD = atrial and ventricular (dual) sensing and pacing n DDDR = same as universal (DDD) pacemaker, with rate-responsiveness—the device will change its pacing rate in response to the patient’s physical activity n VDD = ventricular pacing with dual-chamber sensing (through a single lead). The above codes include the implantable cardioverter-defibrillators. ‘Failed pacemaker’ is not a proper or complete diagnosis. Failure may be intermittent or complete and involve sensing or capture (pacing), or both. A few examples are shown in More examples and details of the pacemaker syndrome and arrhythmias Miscellaneous conditions Chamber hypertrophy Left ventricular hypertrophy Although the ECG is reasonably specific, it is not as sensitive as echocardiography in detecting LVH. The LVH voltage alone may be a normal finding in younger subjects, but in adults over 35 years it usually connotes true LVH, especially if corroboratory findings are present ). Unfortunately, LVH with ST/T changes may be impossible to separate from LVH voltage complicated by ST/T changes of different, especially ischaemic, origin Right ventricular hypertrophy The main criteria for detecting RVH are RAD over +110° and a dominant R wave in V1 (in the absence of its other causes and in the presence of normal-duration QR congenital heart disease conduction defects often come to obscure the hypertrophy patterns.
Cardiologist in Chikkajala, Bangalore • Electronic pacemakers Pacemakers come as temporary or permanent, fixed-rate (although only if they are faulty these days), demand or rate-responsive, atrial, ventricular, biventricular or dual chamber, unipolar or bipolar and as a combination of many of these features. In routine ECG reporting the pacemaker’s exact programming is not usually known, but it is still possible to diagnose the pacemaker type Acute inferolateral infarction with LBBB. Although ST elevation and depression in the limb leads are suggestive, the more discrete elevation in V6 proves the diagnosis (arrows). Within hours, it disappeared and all that was left were primary T wave changes in the inferior leads ). The same patient as in , showing residual primary T wave changes in the inferior leads 90 PRACTICAL CARDIOLOGY Pathological Q waves in all the LV leads in a 90-year-old man with known old anterior infarction Table 3.1 The North American Society of Pacing and Electrophysiology (NASPE) and the British Pacing and Electrophysiology Group (BPEG) generic (NBG) pacemaker codes Position I II III IV V Category Chamber(s) paced Chamber(s) sensed Response to sensing Programmability, rate modulation Anti- tachyarrhythmia function(s) O = none A = atrium V = ventricle D = dual (A + V) O = none A = atrium V = ventricle D = dual (A + V) O = none T = triggered I = inhibited D = dual (D + I) O = none P = simple programmable M = multiprogrammable C = communicating R = rate modulation O = none P = pacing (antitachyarrhythmia) S = shock D = dual (P + S) Manufacturers’ designation only S = single (A or V) S = single (A or V) Note: positions I–III are used exclusively for anti-bradyarrhythmia function. Source: and the all-important capacity to sense the native complexes and pace the appropriate chambers. An international letter code has evolved for describing pacemaker types, shown in Table 3.1. Thus: n VVI = ventricular pacing and sensing, inhibition (in response to sensing)—the pacemaker is inhibited and produces no impulse when it senses a ventricular impulse n AAI = atrial pacing and sensing 3• AN OVERVIEW OF CLINICAL ELECTROCARDIOGRAPHY 91 n VOO = fixed-rate (asynchronous) ventricular pacing, no sensing—this is used for pacemaker testing and is the usual response of a pacemaker when a magnet is placed over it; modern pacemakers are always demand (inhibited) devices n DDD = atrial and ventricular (dual) sensing and pacing n DDDR = same as universal (DDD) pacemaker, with rate-responsiveness—the device will change its pacing rate in response to the patient’s physical activity n VDD = ventricular pacing with dual-chamber sensing (through a single lead). The above codes include the implantable cardioverter-defibrillators. ‘Failed pacemaker’ is not a proper or complete diagnosis. Failure may be intermittent or complete and involve sensing or capture (pacing), or both. A few examples are shown in More examples and details of the pacemaker syndrome and arrhythmias Miscellaneous conditions Chamber hypertrophy Left ventricular hypertrophy Although the ECG is reasonably specific, it is not as sensitive as echocardiography in detecting LVH. The LVH voltage alone may be a normal finding in younger subjects, but in adults over 35 years it usually connotes true LVH, especially if corroboratory findings are present ). Unfortunately, LVH with ST/T changes may be impossible to separate from LVH voltage complicated by ST/T changes of different, especially ischaemic, origin Right ventricular hypertrophy The main criteria for detecting RVH are RAD over +110° and a dominant R wave in V1 (in the absence of its other causes and in the presence of normal-duration QR congenital heart disease conduction defects often come to obscure the hypertrophy patterns.
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