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Wednesday, 26 February 2014

Spring 3 - Mitral Stenosis

'Keeping  ECGs Simple' is an educational blog which runs alongside Twitter.

A new ECG case "quizz" is launched most Wednesday evenings in term time, via @ecgclass, and a conversation/discussion around the case evolves on #ECGclass during the course of the evening. Don't forget the follow the hashtag for the updates during the course of the evening!

Each term will be divided into 5 'classes' or 'cases' to discuss:



Cases are generally aimed at Primary Care.  All scenarios are completely fictitious, but based on commonly occurring presentations in General Practice. 
This is an educational site, intended for healthcare professionals and shouldn't be construed as patient advice. 

Please use the Hashtag #ECGclass on Twitter, if you want to ask the patient any questions, or request any further investigations. Alternatively, please join in discussion and leave comments below.

Remember there are no right or wrong answers!  

ECG interpretation is often open to debate, and will usually evolve and change as new information becomes available.  Everyone's opinion is valid, and useful for others, as the evolution process takes place.  Together we will try and form an interpretation based on the trace, and information, we have in front of us.  Don't worry if you disagree - shout up and share your thoughts - the diagnosis is often arguable on the basis of a 12 lead trace, and may only become more obvious when a longer rhythm strip is available. 

Today's Guest blogger - James Van Oppen.

I am delighted to introduce our very first Guest Blogger on #ECGccass!

Todays case and Twitter feed will be led by James Van Oppen.
James is a 4th year medical student and a commissioned officer with the army cadets. His special interests include pre-hospital emergency care, mountain leadership and expedition skills.

Jamie can found on Twitter @J_vanOppen or on his website

So - with much appreciation and thanks - I will now hand over to Jamie. 
Please feel free to join in, but most important of all, have fun! :-)

#ECGclass case - SPRING 3

The practice nurse has called you to see a new patient who is particularly uncomfortable on arrival for her flu jab. Running late, the 75-year-old lady rushed to the practice and is complaining of “racing heart” and “tight chest”. 
On further questioning she states that she rarely leaves her house nowadays as she gets so tired and can never catch her breath.

Having sat her down and given reassurance, you examine her chest and find her lung fields to be clear. Her pulse is irregular with what sounds like a diastolic murmur. 
You run an ECG while you figure out what to do next:

                                                                                                                                                            Image thanks to

Please use the Hashtag #ECGclass if joining in on Twitter!

If you want to ask the patient any questions, or request any further investigations this can  be done by the hashtag during the course of this evening. 

Alternatively, if referring to this blog at a later date, please leave comments below.

1. Start with the basics: what is the rate? Regular or irregular? 
    Can you see any acute changes?

Using the ‘count the squares’ or ‘3 second marker’ methods, the rate here is about 80bpm. It is clearly irregular. 

note on rate calculation:
‘Count the squares’  - Count the number of big squares between each QRS complex. Divide 300 by this number, for a rough rate.

‘3 second marker’ -  Measure 3 seconds on the rhythm strip (1sec = 25mm, so 3sec = 15 big squares). Count the number of  QRS complexes and multiply by 20 for a more reliable rate when the pulse is irregular.

The ST segments in the lateral leads are depressed – why?

2. Rhythm: can you see p waves? What can you say about the axis?

I can’t see any p waves! So this is AF. 
The crude ‘thumb method’ comparing Leads I (negative) and aVF (positive) quickly shows this to be right axis deviation. 
In addition, that lateral ST depression means this is probably right ventricular hypertrophy – although we are missing the dominant anterior R wave we would expect to see.

Note on quick axis calculation:
‘Thumb method’: Hold your thumbs in the direction the QRS complexes in Leads I (left thumb) and aVF (right thumb) point.
Both thumbs up = normal.
Left up, right down = left axis deviation (what could cause this?).
Left down, right up = right axis deviation (what could cause this?).

3. What other questions might you ask to complete your history?

The lady tells you that she has been having problems with her chest for the last decade but never sought advice, as she was too busy looking after her husband. She gets a tight chest pain and shortness of breath on exertion, and has to put her feet up in the evenings to stop her ankles from hurting.

On direct questioning, she does remember spending a year in convalescence as a child, when she was too unwell to go to school.

4. What is the diagnosis? How are you going to manage her today?

Mitral Stenosis

Mitral stenosis most often occurs in patients who had rheumatic fever. Rarely problematic in the age of antibiotics, in the past this streptococcal infection could escalate to chronic colonisation and resulting damage to the valve leaflets.

The ECG picture of atrial fibrillation and right axis deviation is typical of mitral stenosis. 

Clinic-based management is to treat the heart failure and anticoagulate. These patients are at increased risk of infective endocarditis and may require prophylactic antibiotics before invasive procedures. 
The extent of valvular damage and lumen viability can be assessed by echocardiogram, allowing decisions whether balloon valvuloplasty or valve replacement would be worthwhile.

Thank you.  :)
Hope you enjoyed tonights class! 
Please feedback to @ECGclass or @j_vanOppen

Don't forget, to recap what we've learned, your full discussions and Twitter interactions will be loaded up to Storify next week! :)


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