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🫀 10 Common Heart Diseases — ECG Changes (NEET PG / FMGE Guide)

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1. 🔴 STEMI — ST Elevation Myocardial Infarction

What happens?

Key ECG Changes (in order of evolution):

Localisation (must know for MCQs):

MCQ Tip: Reciprocal ST depression in opposite leads confirms STEMI (e.g., inferior STEMI → ST depression in I, aVL).

ECG — Anterior STEMI (tombstone pattern, V2–V5):

ECG — Inferior STEMI (ST elevation II, III, aVF with reciprocal changes in I, aVL):

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2. 💜 Atrial Fibrillation (AF)

What happens?

Key ECG Changes:

• ❌ No P waves (replaced by fine fibrillatory f-waves, best seen in V1)
• ✅ Irregularly irregular R-R intervals
• QRS is narrow (unless aberrant conduction)
• Ventricular rate variable (can be fast, normal, or slow)

MCQ Tip: "Irregularly irregular" = AF. Most common sustained arrhythmia. Causes: valvular disease (especially mitral stenosis), hypertension, thyrotoxicosis, alcohol.

ECG — Atrial Fibrillation:

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3. 💙 Complete Heart Block (3rd Degree AV Block)

What happens?

Key ECG Changes:

• P waves present at their own rate (faster, ~60–100/min)
• QRS complexes at escape rate (slower, 20–40/min)
• No relationship between P waves and QRS (AV dissociation)
• QRS wide if ventricular escape, narrow if junctional escape

MCQ Tip: "P waves march through QRS complexes" = 3rd degree block. Requires pacemaker implantation. Commonest cause: ischemic heart disease (inferior MI involving AV node).

ECG — Complete Heart Block:

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4. ⚡ Wolff-Parkinson-White (WPW) Syndrome

What happens?

Key ECG Changes (Classic Triad):

1. Short PR interval (< 120 ms) — fast conduction via accessory pathway
2. Delta wave — slurred upstroke at start of QRS (slow conduction through ventricular muscle)
3. Wide QRS (> 120 ms) — due to delta wave

MCQ Tips:

• Type A WPW: Positive delta wave in V1 → left-sided pathway
• Type B WPW: Negative delta wave in V1 → right-sided pathway
• Can cause SVT (AVRT) — most common arrhythmia
• Never give digoxin/verapamil/adenosine in WPW with AF → may accelerate conduction → VF
• Treatment: Radiofrequency ablation

ECG — WPW Syndrome:

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5. 🫁 Pulmonary Embolism (PE)

What happens?

Key ECG Changes:

• S1Q3T3 pattern (most classic MCQ finding):
  • S wave in Lead I
  • Q wave in Lead III
  • T inversion in Lead III
• Sinus tachycardia (most common finding overall)
• Right axis deviation
• RBBB (complete or incomplete)
• T inversion V1–V4 (right ventricular strain)
• P pulmonale (peaked P in II)

MCQ Tip: S1Q3T3 is classic but only present in ~20% of cases. Sinus tachycardia is the most common ECG finding in PE. Must exclude STEMI (PE can mimic inferior MI).

ECG — Pulmonary Embolism (S1Q3T3):

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6. 🟣 Left Ventricular Hypertrophy (LVH)

What happens?

Key ECG Changes:

• Voltage criteria:
  • Sokolow-Lyon: S in V1 + R in V5/V6 > 35 mm
  • Cornell: R in aVL + S in V3 > 28 mm (men) / > 20 mm (women)
  • R in aVL > 11 mm alone
• LV strain pattern: ST depression + T inversion in V5, V6, I, aVL (like a "strain" pattern)
• Left axis deviation
• Prolonged QRS

MCQ Tip: Most common cause = systemic hypertension. Sokolow-Lyon criteria most commonly tested. LV strain = asymmetric T inversion in lateral leads.

ECG — LVH with strain pattern:

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7. 🟠 Acute Pericarditis

What happens?

Key ECG Changes (4 Stages):

MCQ Tip: PR depression = pathognomonic of pericarditis. Cause: young adults — viral (Coxsackie B), post-MI (Dressler's syndrome), uraemia, SLE.

ECG — Acute Pericarditis:

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8. ⚠️ Ventricular Tachycardia (VT)

What happens?

Key ECG Changes:

• Rate: 100–250/min
• Wide QRS (> 120 ms) — bizarre morphology
• Regular rhythm (monomorphic VT)
• No P waves visible (or AV dissociation)
• Capture beats and fusion beats (pathognomonic of VT)
• Concordance in precordial leads

• No RS complex in any precordial lead
• RS duration > 100 ms
• AV dissociation
• Morphological criteria (notching of downstroke)

MCQ Tips:

• All wide-complex tachycardias = VT until proven otherwise
• Torsades de Pointes = polymorphic VT with twisting QRS around baseline → seen in long QT syndrome
• Treatment: Amiodarone, DC cardioversion if hemodynamically unstable

ECG — Ventricular Tachycardia:

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9. 🔵 Hyperkalemia

What happens?

Key ECG Changes (progressive with rising K⁺):

MCQ Tips:

• First ECG change = peaked T waves (not tall, but narrow-based and symmetric)
• Cause: CKD/renal failure, Addison's disease, K-sparing diuretics, ACE inhibitors
• Treatment: IV Calcium gluconate (membrane stabiliser, immediate) → Insulin + Dextrose → Sodium bicarbonate → Dialysis

ECG — Hyperkalemia (peaked T waves + QRS widening):

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10. 🩵 Right Bundle Branch Block (RBBB)

What happens?

Key ECG Changes:

• Wide QRS > 120 ms (complete RBBB); 100–120 ms = incomplete
• rSR' pattern in V1 ("M-shaped" / "rabbit ears") — signature finding
• Wide, slurred S waves in I, V5, V6 (lateral leads)
• T inversion in V1–V3 (secondary repolarisation change)

MCQ Tips:

• "WiLLiaM MoRRoW" mnemonic: LBBB = W in V1, M in V6 (William); RBBB = M in V1, W in V6 (Morrow)
• New RBBB in chest pain = right heart strain → think PE or RV infarct
• RBBB alone in young = often benign
• Causes: PE, cor pulmonale, ASD, cardiomyopathy, congenital

ECG — Right Bundle Branch Block:

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🧠 Quick MCQ Recall Table

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💡 Study Tips for NEET PG/FMGE:

• Learn lead groupings by territory (inferior = II, III, aVF; anterior = V1–V4; lateral = I, aVL, V5–V6)
• Practice "Which artery is blocked?" questions using lead localisation
• PR depression = pericarditis (almost always comes as a 1-liner MCQ)
• WPW drugs to AVOID: Digoxin, Verapamil, Adenosine (in AF with WPW)
• Complete heart block → Pacemaker; VT → Amiodarone/DC cardioversion

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🫁 Boerhaave Syndrome — Complete NEET PG / FMGE Guide

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🔑 What Is It?

Named after Dutch physician Herman Boerhaave who described it in 1724. Historically uniformly fatal until 1947 when the first successful surgical repair was performed. Current mortality: ~20–40% (highest of all GI perforations).

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🧠 Pathophysiology — How Does It Happen?

Forceful vomiting / retching
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Sudden ↑ intraesophageal pressure
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Closed glottis (no pressure escape)
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Intrinsic weakness of LEFT POSTERIOR WALL of DISTAL esophagus
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FULL THICKNESS TEAR (transmural)
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Gastric contents → Mediastinum → Pleura
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Chemical Mediastinitis → Sepsis → Death

Why left side? The distal esophagus is anatomically weakest at its left posterolateral wall, just above the gastroesophageal (GE) junction — hence left pleural effusion is more common.

Why no serosa? The esophagus is the only GI organ without a serosal layer, so once the wall ruptures, there is no barrier — contents leak directly into the mediastinum.

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📍 Site of Rupture (MCQ Favourite)

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⚡ Classic Cause & Triggers

• Weightlifting
• Childbirth / labour straining
• Defecation (Valsalva)
• Seizures
• Coughing / asthma attacks
• Blunt abdominal trauma

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🩺 Clinical Features

⭐ Mackler's Triad (Classic MCQ Triad)

"Vomiting → Chest Pain → Subcutaneous Emphysema"

Other Clinical Signs:

• Hamman's sign — Crunching/crackling sound heard on auscultation synchronous with heartbeat (due to pneumomediastinum) — pathognomonic
• Dyspnoea, cyanosis
• Fever, tachycardia (signs of mediastinitis)
• Dysphagia, odynophagia
• Signs of septic shock if delayed

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🔴 Boerhaave vs Mallory-Weiss — High-Yield Comparison

MCQ Tip: Mallory-Weiss = blood in vomit. Boerhaave = chest pain + surgical emergency.

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🩻 Investigations

1. Chest X-Ray (First line / screening)

• Pneumomediastinum — air around mediastinal structures (earliest sign)
• Left pleural effusion (or hydropneumothorax)
• Subcutaneous emphysema in neck
• Widened mediastinum
• Naclerio V-sign — V-shaped gas collection at left lower mediastinal border between parietal pleura and diaphragm (pathognomonic on CXR)

2. ⭐ Gold Standard — Contrast Esophagogram (Gastrografin swallow)

• Use water-soluble contrast (Gastrografin) first — shows extravasation of contrast outside esophagus
• If negative but high suspicion → use barium (more sensitive but causes chemical mediastinitis if it leaks)
• Confirms diagnosis + localises the site

3. CT Chest (best for complications)

• Pneumomediastinum
• Pleural effusion / empyema
• Esophageal wall defect + contrast extravasation
• Mediastinitis (fat stranding)

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🖼️ Imaging — Boerhaave Syndrome

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💉 Treatment

Emergency Surgery (Mainstay — within 24 hours)

Conservative (selected cases only)

• Small, contained perforation with no mediastinitis
• Nothing by mouth (NPO) + IV fluids
• Broad-spectrum antibiotics (cover oral flora — gram positives, anaerobes)
• IV PPI (decreases chemical mediastinitis from acid reflux)
• Close monitoring

Endoscopic Treatment

• Endoscopic stent placement (for contained tears)
• Endoscopic clipping

MCQ Tip: Primary surgical repair within 24 hours = best outcome. After 24 hours, mortality rises dramatically. Always give IV antibiotics + IV PPI as adjuncts.

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⚰️ Complications

• Mediastinitis — most dangerous, life-threatening
• Empyema (pus in pleural space)
• Sepsis / Septic shock
• ARDS
• Esophageal fistula
• Tracheo-esophageal fistula

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🧠 High-Yield MCQ Summary

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🗂️ One-Liner for Quick Recall

"Middle-aged man, heavy meal + alcohol, forceful vomiting → sudden tearing chest pain radiating to back + neck crepitus → Naclerio V on CXR + Gastrografin leak = Boerhaave → Immediate surgery"