Thank you, Doctor. Very generous comments and welcome to everybody. That's a very eclectic aureus. And so I've tried to include something for everyone. You'll notice I've simplified the title because it wouldn't fit on this page. And I have also been experiencing a little Mac conversion problems are coupled by size. You have to be patient with me. Said, let's go ahead and get started. Orthodox electrocardiogram. Put simply stay for our purposes today. Recording at the body surface electrical potentials representing the salvation of atrial ventricle depolarization and ventricular depolarization. There's a lot more going on electrically and a heart for pieces of things that are reflected at the state level that we record on the electrocardiogram. Basically, in addition to giving us the specific pattern, the electrocardiogram allows us to estimate what the cardiac impulse is coming from, where it terminates, and how it got there. First of all, let me read, argue hard for this, this. And the answer is very useful. If perhaps the most commonly used immediately available, the tool that we have an acute care medicine. It's available everywhere. It's easy to perform. Results are immediately available for interpretation. And it is relatively inexpensive that'll fit medical testing. Those. We currently do over a 150 thousand a year at NYU Medical Center campus. So it is both useful and very much use. The kind of information we get from the electrocardiogram really falls into two buckets. First of all, it is a fast way to identify specific cardiac conduction disorders. So that's one part. Secondly, it allows us to look at characteristic electrocardiogram that can give you important information about Chamber enlargement. For example, left ventricular hypertrophy or pipe ventricular hypertrophy. Parchment, asymmetric settlement hypertrophy. It is the way that we immediately make the diagnosis of acute coronary syndrome. And there are some congenital heart disorders that we can recognize from the electrocardiogram. The electrolyte if metabolic abnormalities, particularly at the IU, many of those transistors, because we've got a five-year for decades ago and I'll give you an example. And finally, we could subpaths effect, drug effects and toxicity. I put this a few selected points because these are examples of how electrocardiogram is immediately available in life-threatening situations, like a corner, etc. For example, the detection of acute myocardial infarction. The benchmark is forced to make the diagnosis within ten minutes of presentation to the board, and within 90 minutes for us to have opened the occlusion at Harvard. You already within 90 minutes. So not making the appropriate MBTs electrocardiographic diagnosis places the patient Jeopardy. Cardiac boss is directly applicable to the duration of that might. Similarly, there are some life-threatening electrolyte and metabolic abnormalities and certain drug toxicity states. For not recognize. Cartographic everybody can place the patients like this. Ever getting to the two or three didn't translate well. So you'll still and we're able to to see me trying to make here. Just to remind you that the production or the impulse at the heart of the scientists tell the cycle. And that you could Seeger and experienced neurophysiologists good. Diagram that results in the atrial depolarization. If that's what you see, you don't see on the electrocardiogram size. Based on the appearance of the atrial depolarization. We infer from this side, your pulse that travels from the atria to the ventricles traversing the AV node and this area are conducted is slowed. Datacenters ventricular conducting system. So there is a photo here, a right bundle branch block. Production and reproduction goes here and it occurs is such a beautifully symmetric and sequence the way that the entire depolarization Arabic texts, less than 20 milliseconds. Anything, it erupts conduction in one of these things disrupts that, changes the pattern and the duration of that depolarization that we recognize them. So we can recognize characteristic patterns. Not fossil plants block right off the bat spot, complete heart block, block up here. All things. But we don't actually see the construction itself. What we see is the manifestation because it is the depolarization of the vessel because offered a new space that allows us actually to make the appropriate diagnosis. Now, I underline this electrical activity that begins as I showed you, that the conduction system results in a much recession that is translated into the skin to taxes and we record all of that is due to the electrical activity on your wagon. The heart tissue at the various parts of the heart actually have action potentials that are different. But notice the satisfactorily recall has property of spontaneous depolarization. And that little different drastic Professor Martha circumstances therefore, is the pacemaker of the heart. All of these you don't see, although we do see the manifestations, we see the ventricular muscle backing it up. So here is a symbiotic cartoon. Capital relationship, how those various action potentials and follow possession results in the electrocardiogram. So we start out with atrial depolarization occurs as a result that the status quo, the taxes last feedback diagram. We have conduction through the $80, which we can see that it slows events. So we have the PR interval and then we have the depolarization of the ventricles, which gives rise to the characteristic QRS. Production is not a very nice spell. Less milliseconds. And then we polarization the curves. Of the two. We record the bipolar and unipolar pericardial, our chef, he's going from the right side of the heart over to the left side. And we can look at the relative voltages from the two sides of the heart. So it results in a lack this standard electrocardiogram with a key way, a nice narrow QRS, nice normal ST segment at a normal TTY. This is a electrocardiographic pattern and the various literally six here and a recording of these biosensor pocket the parcel. From an electrical perspective, we see the particular forces become greater and greater gigabytes here as we go across the aperture to hypertrophy this voltage here at the left side of the heart of the budget increase. That would probably be some hacker about undermining the change in the electrical axis or the heart, or to the left. To the pattern of the QRS complex is this look at this here. But you see it's not that you got TVs will pass and you got to go. This is a 27-year-old, young individual. But what could cause? Well, it could be something wrong with the science that right size here satisfy the curve repaired it. Could be heart that well no, because they don't CFP YFP or they didn't see. This path will get you collected interpretation where you test out, think one of the pieces and Google thought we look very carefully. You'll notice that this is different, but that is different than them separately. And it occurred earlier that the API was still refractory, physiological refractory, and therefore did not connected. So this is not heart disease, this is at most 2k. The fact that they haven't atrial three, which will be very calm and structural arts. Let's copy the actual setting for them as well. Though, like you sort of had that general pattern like this. But this is I absolutely can't be 47-year-old gentleman. And again, it's the careful examination of heavy deduction. The fact that the Innu, after the scientist put that sign of peace should come right here and then erupted was the cause of that interval premature v. Now, we know from our colleagues in basic science for a wide variety of highly complex ion. But across the transmembrane component of the heart cells that live, it's actually potential. And I provided the polarization state that we record on the electrocardiogram. But it's interesting. Choreography is different than some medical advances. And it began with a seminal observation and domestic Labrador. And they go through basic translational. And the bench to the bedside. Left cartograms sort of backwards. It became a tool that will shoes and then move to the fence, to the basic mechanisms. And now we've taken the new college back Zoe. And again, to take the field even part. So thinking analysis today, considerable degree and what it started because almost exclusively clinical electrocardiographic polis as just observe hundreds and thousands of electrocardiogram? No, that that certain patterns occur in certain situations. And then through the power of the fact that exactly the analysis, we have to figure out about their tax revenues. And it's amazing how correct they were, right. And we know that now from the basic studies and invasive studies we do in the laboratory, we've extended that further now with the of that side. And we're also happy, and of course, it's a cardiac electrophysiological studies in humans to further understand this relationship. So here's another example of one of those diagrams to demonstrate recognition of the pattern is so critically important. Along with this time, it's the same format that's 123 are recorded. I think that was like who is this ST elevation right here. The coercively T3 and API that the setting of a gentleman having chest pain, this is a characteristic pattern of acute myocardial infarction or heart attack. Moreover, we know this is the kind of heart attack then at about 90% of traces to an acute pragmatic occlusion of the vessel. Annotation because of its location and these empathies associated the cyclical changes. We know there's about a 90% chance that it's due to the right corner. We tell that this patient has pointed out. We see this right ventricular involved as well. We know that this is occlusion of the past or to the right ventricular grams right corner. So this is a five, this Next cartogram, displacing responsibility within 60 to 90 minutes, and it's based on the electrocardiogram. We also know that because of this location, there are certain other complications that this patient is at particular risk for. One of those is to develop second-degree be blocked at the level of VAB out. Director also supplies the most people. And here's just an example of the kind of the same exchange that's short of victory parts. You see what people have actually spontaneously or they have a party's stress. This is the change of the SDK reflection that resetting SAP and the cardiovascular area. Then it becomes a cross, a Global Persistent sticker. That's when you see the ST elevation we saw before. And in this space to do that, this, or that product that during this class that you can see is that this effect is over and got this electrocardiogram has normalise. Well, I said that this field began by observation, so some fundamental principles and clinical correlations from master clinicians. He's the guy who witness without a drag Hogan. 1947 is really the father of elect cardiac. Other sad record is some electrical potentials. But he was the one who developed the strength galvanometer. At five, they set a vision for clinical use. Really was more of a science aesthetically. After he hates ads devices, he really didn't care very much how it was used in the collaborative clinicians start to manufacturers. And he won the Nobel Prize in 1924. There was this machine. You can see this. It's not for portable. With happiness. And fear is a compendium showing the buckets of water or conducting solution and the recording electrode closer to what we do right now. And here's a blow up of this guy again to show the P QRS T by remarkably similar to what we recorded the day visit Province employ medical certain. I think that really introduced by setting the flags. And to show you that recognize normal, Look at this trip to see these two waves marching through here. And you'll see the QRS soup and the two guys. Dualism, arg2. And so this is a patient will partner with us with advice about the Soviet state as coming from the API. Just venture. And therefore you, those are the level. And our colleagues. This is the piece changes that thought before. Even the presence of all of the complex anatomy of the ordinary. Really remarkable. I wanted to show you that will make you back too. Because if you're a regular basis by which we are talking about a gradual prolongation of production. Meaning there's a, there's a delay, progressive delay coordinate. And in that conducted the actuating back is the one who identify that really, I really didn't like the electrocardiogram. The other came back in 1903 to describe the phenomenon. I put this in here that the hydrography though I think the cause of this master condition and how much that side vibration is important. If you're going to be finishing d2y feedback. Identify this phenomena. But looking at the veins and the arteries, and that this cycle repeats and repeats and pass. The additional cycle. Foundation with Vegas was the first cycle, less of the stack and you had to pass and reduce the mechanism of the second. And here he is paradigm that we measure today. Just look at this guy here. Notice first of all, the weights here are perfectly regular. So this is what we saw before. But you'll notice that the Vr integral, gradually, Norma here gives me walk. The walk is still making. His charisma is characteristically I figure out if you are highly regarded, your sleep and have high vagal tone. But it's characteristically plaza insert has a heart attack, including that one I showed you a fortune. And if a victim to medications and intrinsic gave me no disease as well. Characteristic that I wanted to show you with these and demonstrate how that came to me. And that is the matter, the Triassic complete pipeline. And once again, these things don't have any relationship to the marching through. And you'll notice now we have Y two are complex and that's because the escape where they're coming from and the vector, that's high risk situation. And you can see that Florida is two. This is the heart rate of about 30 or 35. Or the next guy. For clinical Caryatids. He, that guy is the real hero of the Development. Doctor. Thomas's subsequently Sir Thomas Kuhn. Identify a broad range of complexity that we see in the clinic. And I can see it better than I published a classic book which is still used today. To look at the background of certain rhythm analysis principles. I want to turn to a more modern era. This is Dr. Charles fish from IU pack the thesis, the founding director of the creditors to repack algae was the founding director of the credit is to rheology. Like fish. For the master clinical record. And one of the top two or three present the private cardiology seminal text on the electrocardiographic pop. An entire generation of political geographies. And basic lowercase laboratory work included characterizing the effects of potassium on cardiac tissue and e, c v, and also the effects of cows and other medications. And in fact, patients with those ages on cardiac did witness. Give an example of some of that? Here is a pricing that is characteristic of hyper cooling. You'll notice how Father Pete values are here. That's characteristic and their narrow phase. These are the kind of things that he demonstrated initially in animals and in humans as characteristic changes of hypokalemia. Another one that can be life-threatening if not identified, probably. It so happens this tracing this patient also has a prolonged as the segment and that's from hypercalcemia. So here's an example of the combination of hypokalemia, hypocalcemia. Can you think of a situation where you might encounter that's got it doesn't definitely. Styles of dialysis patients frequently will be somewhat hypercalcemia and that's allowances or so. And they're like my grandma's like this. This is a pretty characteristic pattern of a dialysis patient roadmapping appropriately Darwin. In fact, this is a 30 year old that, something like that. I want to show you how this is how I met at University Hospital. One of the key artist who's down the hall and ask you about drum right down to the emergency room. And this man was responsible. And this is stiff. And if you had trained the factor fish and Reddy's book, this is the tracing of profound hyper tailing. Preparing for the electrocardiogram and essence becomes a sine wave and everything is full that you usually can't even see the p one. This is a life threatening form of hypokalemia. And he was a vow suspension that candidiasis and decided he would rather have somebody cafeteria. Thank you. Became we can pass out. And in fact, this is electrocardiogram after treatment and this was probably reversible just by taking care of the potassium. He did well and went down the hall to the Dallas assume. By contrast, here's hypo. Okay, I think I've told you a hiker feeling thought. And nowadays, there's very low P5 over here. And in fact, we have this extra done this extra properties of Youwei, which becomes more prominent in hockey and hypokalemia. So here's the passionately treated for hypertension and empathy being vigorously value-based. Oberth Azure Reese. And this resulted in a dangerous level of hypokalemia. Serum potassium is at a level that is dangerous encoded to South ellicit additional cardiac rupees. With just an example about how this is working in the laboratory is original laboratories at the old crater Institute on history. That in the face that was, it's subtle what a seminal experiments were done. And then taken to the political arena and use now sonically everywhere. He was not the only one, of course, who participated in these demonstrations and this recognition, but he played a leading role and certainly in dissemination as well. After factor fish 5V, we had recruited a young electrophysiologist, Dr. Douglas sites, who came to us just factory, finished fellowship and got out of the Navy. That decides who's one of the first developers. And electrophysiological studies that characterize many of the things, the mechanism for many of the things we have been looking at. He also play a central role in elucidating the optimal tree plus for sudden cardiac death. He chaired the taskforce and identify athletic guidelines and evaluation guidelines regarding competition. Had normal cardiac evaluation. He also was the president of the American College of Cardiology. Wrote the seminal textbook and electrophysiology and electromyography after back fish. And he played a leading role in the development of anti tachycardia. All devices such as ICTs and anti suppressing drugs and devices. And makes an emeritus member of our faculty and active Arthur electrophysiologist sends a pen Shuangcheng because our current director and whose work is an atrial fibrillation thought this continuum is quite impressive to began with Dr. fish, to take advantage of the next level of the invasive studies and the, and the treatment modalities. Now back to the basic laboratory practice, Chan understanding the mechanisms so we can go even further. I think is a rich heritage that we can be proud of. Here is an example of ventricular tachycardia, the kind of thing doctors, I spent his career looking at why rapid QRS complex. We know from the parents of the morphology, but this is likely to be ventricular tachycardia. But if, if you have paid close attention, you've looked down here and seen that these key ways again, are marching through independent. But here they're marching through not because they're hard block. There's what's called interference. If they had a chance they conducted the ventricle, is just there being interfered with by this independent activity arising within the ventricle in this life-threatening ventricular. And here's a slower version, so-called idiopathic, or our ideal ventricular revenue. Or you have the ventricular realm here and then an occasional scientist v. And in fact you have this one where the P-wave is in here, that is sort of between the two. And this is a fusion B. So the farther the ventricle coming from the ventricular focus depolarization harder but from supraventricular folks. Now, so I started with the early observations, humble observations with equipment for never used anywhere. It's rapid translation into clinical arena based largely on empirical observations of master clinicians. To the next level of understanding a little bit more about the mechanisms and extending it. So really being incorporated into clinical decision-making. And now I want to assure you that we've not been static with the electrocardiogram. That research, clinical and basic continues. Some of the more recent advances include differential diagnosis to wide QRS, complex arrhythmias, the mechanisms of supraventricular tachycardia, CG patterns associated with sudden cardiac death, including a number of congenital syndrome like congenitally prolonged QT interval, outflow tract, ventricular tachycardia we've now can localize by fast tracks and fragment Fraser fragmentation changes in the QRS in acute myocardial infarction. So it remains amazingly important part of our treatment, particularly of acute care of patients. And provides not only random but also pattern, also prognostic, also Friedman decision. It has its limitations of course. And some of these patterns can be simulated by other conditions. But bias longevity now over a 100 years as a clinical fool has demonstrated its effectiveness. How I wanted to show, I can speak about cardiology and Indiana, and I'll show this slide because this is a faculty member who started out working with Dr. fish and looking at the effects of intravenous potassium on the electrocardiogram in an animal model. Fears, it will surprise you someone from the crowd and who did not really like the electrocardiogram. And so he turned his attention to this machine here. This is dr. Harvey vagabond, who is the father of clinical echocardiogram three, the other major focus of the credit history of cardiology. And he has over a career that has spanned 50 years, become the leader in the world in clinical echocardiogram. And made those developments to some extent because he didn't particularly like potassium and an electrocardiogram flow more truth in that. So I thought then I finish with this slide. And Anna, sister one that comes with it. So I want you to look at this electrocardiogram and an 18-year-old asymptomatic. Somebody, first of all, what strikes you anything unusual in this price? Based on the few things that we've learned today. Does this look like a normal V1? No. You're right. What's this look like? Just like a normal V6 than it should be over here? But it's not it's still down over there. So it looks like all of the left ventricular forces are over on the right. You see the same thing over here and lead one mark ship in the electrical axis of the heart to the right. These asymptomatic electrocardiogram otherwise looks norm. How the world could that be? This is algebraic, extra ParDo. So simply made by the electrocardiogram fever than that x-ray? I so I think that's yeah, that's all I'm gonna say. I want to thank you and I want to thank Dr. holds for his leadership in this conference. We were invited me to come. I'd be happy to answer any questions you might have. Thank you. Right? Well, there are a number of metabolic we've got the simplest level. It's the electrolytes and the acid-base changes, changes occur with acidosis, with systemic alkalosis, and with the electrolyte abnormalities, there are likely other things that can contribute. For example, I, I know you have an interest in glucose metabolism and whether that could play a role. And there certainly are postprandial and prefer and you'll changes that take place in electrocardiogram. Actually duckface played an important role in that. And I'm confident that in the extreme, there are a number of metabolic issues that could contribute to electrocardiographic changes or maybe even to a arrhythmia occurrence. But as you know, that's a complex area about which there's still not a great deal, not just yeah, it remains number one in the country, better, substantially reduced from before. The trend, as you know, the longevity of a life span for both men and women in this country is the greatest now that it's ever been in new HIV recorded history a man. So there have been dramatic improvements. Interestingly enough, the improvements have been more translated in men than in women. And are still as much to do. And it's still a prevalent disease. You're absolutely correct. We usually start out by saying. These kind of talks when we speak, for example, for the American Heart Association by saying there is good news and bad news. And the good news is over the last decade or two, there's been a dramatic decrease in the frequency of death, myocardial infarction and stroke. The bad news is still the leading cause of death. In some areas, by the way, it's now cancer but pretty close. And we haven't extended those benefits across every month. To some extent. It's the result of the co-morbidities. As best we can tell, the advances we've made have been about 50% due to the things cardiologists do when they're taking care of heart attack patients. But about 50% of the benefit is due to lifestyle changes that people have done to decrease prevalence of smoking, for example, grasping most important. But now we have this epidemic of type two diabetes and obesity. And great concern that as the population even expands further, there will be a corresponding rise again in cardiovascular morbidity and mortality. It's interesting, it's a different disorder though acute coronary syndrome center was when I was a fellow. I mean, a typical patient we saw when I was a fellow come again with one of those ST Elevation Myocardial infarction was a forty seven, forty eight, fifty year old man. And now it's more typically a 6568 year-old man or a 68 or 70 year old woman. So there has been and and again, that's partly due I'm sure to respect women. Yeah. I'll tell you what I think will happen now say when they should happen. First of all, the echocardiogram is a great tool for looking at structure and for looking at function. So if you want to see how vigorously the heart is conducting, if you want to see if there's a pericardial effusion, it is an invaluable tool. And I do think increasingly the small ones will be found to have clinical utility. We now use in an emergency room, for example. And hazardous in our trauma center. If a patient comes in with a steering wheel injury, the chest pain or call us down from cardiology to do the echocardiogram. They drove himself with overhear, signing for those structure and functioning. It will it will be great. Here, will never allow you the ability to diagnose and recognize complex arrhythmias. And there are some disorders that are, that price people at risk that are not manifested by the structural frame. Many of those disorders I showed you how you're going to have life-threatening hyper feeling and an absolutely normally function hard until all of a sudden, it's not coffee. So I, I don't think the electrocardiogram will be. Will be shunted aside. So I think the hacker will grow. You'll be an integral part of it. Here's what I don't want to happen. I don't want it to replace the physical examination. And I don't want the younger generation of physicians to not fully appreciate haulage and get out an electrocardiogram. There's great concern even among our cardiology fellows, that they're not as skilled in the use of the electrocardiogram as their colleagues a generation ago. Because they've got other things on their flight that they have to master as well, including echocardiogram? Yeah. Yep. I'm fortunate. Well, let me take the ladder when first, unfortunately, the computer interpretations are not infrequently wrong or incomplete and occasionally dangerously wrong. So as to be very careful about that. They can measure intervals very well. But when they start trying to make clinical correlations, I'm sometimes fall short. I do. Thank you. Can identify the kind of things that a practicing physician needs to be able to recognize. And there's such things as two or three life-threatening algorithm is the changes of acute myocardial infarction and a couple of electrolytes. What are the kind of things that a practicing physician generalise right now? Like also now because of the digital age. If I get a call from an emergency room and New Castle and they can improve electrocardiogram. You know, in the old days I'd have to drive to some place that had a fax machine or I don't have to buy, wanted only half the battle on it. It would be a terrible copy. So now they discounted and the computer 30 seconds later and I can interpretive form. So I'd like the other party. Your answer is all of us will have resources, point-of-service resources that we can invoke to give us that immediate interpretation? Yeah. While Leo, First of all, I don't want to mislead people, it is common for the computer interpretations to leave out a piece or the over-exaggerate something. It is not common for them to make critical, life-threatening kinds of errors. And the electrocardiogram will say on it, this is an unconfirmed electrocardiogram to be reviewed by a physician. And that's another one of the reasons why there's certain proud of we should expect positions to be able to recognize. But it is a potential problem. It's uncommon for today's dramatic, as you've just said, we're somewhat banks, you've had a heart attack or heart attack and are granted when saying that frightening. But at the end of the day, it's still a position we should be making the decision, not a machine. Hazard. I don't think I'd be quite definitive because there are a few screening length. For example, if we have someone who has a family history of hypertrophic cardiomyopathy. The kind of thing that actually sometimes that suddenly we will do screenings of the first order relatives or that person with an ECG and an echo without examining them because we know how to answer that specific question. The echo and ECG are okay. But if you're talking about clinically evaluating a patient for individual risk assessment, our treatment decisions or diagnoses. It should always be in the context of the physical examination and a physical examination should come first. Yeah. It's a controversial question. When should people have stress tests? I can tell you the official Society guidelines are, if you a have symptoms, little chest discomfort, a little unexplained shortness of breath with activity. The most important arc you have some of other objective abnormality. Let's say you're resting electrocardiogram suggests there had been a problem. And then a third category of people who are undertaking certain high-risk situations are going to do something unusual. If you get to be 55 years old and you suddenly have a midlife crisis, you've gotta go climb Mount Kilimanjaro and you've never done that sort of thing before, or you're going to run a marathon then yes, you should have a stresses. But we do not routinely do the stress test. An asymptomatic individuals who do not have multiple risk factors or other problems. And the reason for that is that there's a certain incidents of false positive and we can end up going down a slippery slope of next does the next thousand an excess is Doug McCarthy was outlining as a possible problem. So symptoms to be evaluated. High-risk clinical situations such as multiple risk factors or other abnormalities are thirdly, individuals who are going to do something unusual. We stress that all of this place and the fire department, but they don't do usual things. May do unusual things. Thank you all very much. And I'm happy to do it. I use the SEC all along. But then when I tell them is look when we Yeah. Yeah. Yeah. Oh, probably a habit. It was the very free. Yeah. Yeah. Yeah. Yeah.