Top Ten (or 11) EKG Killers
Micelle Haydel, MD
LSUHSC New Orleans
Credit to Amal Mattu, MD
Lectures: ACEP EmedHome Podcasts Visiting Lectures
Books: ECG's for the Emergency Physician 1 by Mattu & Brady ECGs for the Emergency Physician 2 by Mattu & Brady Electrocardiography in Emergency Medicine by Amal Mattu
The EKG must be interpreted in the clinical context.
Don’t order a test unless you know what to do with the results…
The Normal Adult EKG
Majority QRS complexes are positive (have tall R waves) Except AVR & V1-2; r-wave progression across the precordium T wave in V1 should be small, flat or flipped
Differential Dx of Tall R waves in V1
Posterior MI RBBB Right Strain
PE COPD Cor Pulmonale
RBBB mimics PE Brugada ARVD WPW
Pediatric EKG (tall R-wave and flipped t-wave V1-3)
Specific causes of non-specific flipped T-Waves
CAD/ischemia Cardiomyopathies Myocarditis, pericarditis PE Valvular disorders CNS bleed
LVH, BBB, paced
Differential Diagnosis: Tall t-waves
Hyperacute T-waves/ischemiaHyperKalemia
BER LVH, BBB,
Paced
Low voltage: qrs <10mm precordial
Obese patient The New Orleans’ Special
Restrictive cardiomyopathy Pericardial effusion Hypothyroid Hypothermia Myocarditis
The EKG must be interpreted in the clinical context.
Don’t order a test unless you know what to do with the results…
EKG in Syncope, PreSyncope, Palpitations
Is it Syncope--
Cardiomyopathies Dilated Hypertrophic Restrictive ARVD/C Arrhythmogenic Right
Ventricular Dyplasia/Cardiomyopathy Primary arrhythmic syndromes
WPW QT intervalopathies Brugada ARVD CPVT Catecholaminergic Polymorphic
Ventricular Tachycardia Not-so BER
Other Biggies MI Pulmonary
Embolism
or is it a sentinel death event??
Sudden Cardiac Death: unexpected death within 1 hour of symptomsFinal, common pathway: Vtach/fib 90%
~300,000/yr in US Over 35 years
~80% due to CAD ~15% Cardiomyopathy
NEJM Huikuri et al. 345 (20): 1473, November 15, 2001
Sudden Cardiac Death: 1-35 yrsFinal, common pathway: Vtach/fib 90%
~3,000/yr U.S. ~70% have a structural abnormality
Cardiomyopathies Coronary Anomalies Myocarditis Valvular Disorders
Primary arrhythmic syndromes Accessory pathways QT intervalopathies Ion channelopathies
0%
5%
10%
15%
20%
25%
30%
Identified Causes SCD 1-35 years
HCM
CoronaryAnomalies
Myocarditis
Valvulopathies
Primary arrhythmicsyndromes
ARVD
EKG findings in Sentinel Death Events
Cardiomyopathies: (flipped T waves plus…) Hypertrophic Cardiomyopathy (LVH) Dilated (LVH) Restrictive cardiomyopathy (low voltage,a-fib,
conduction disturbances) Arrhythmogenic Right Ventricular
Dysplasia /Cardiomyopathy (Epsilon waves, RBBB pattern)
EKG findings in Sentinel Death Events
Primary arrhythmic syndromes Brugada coved/saddle deformity ST V1 &V2 WPW Delta waves, short PR interval, RBBB pattern Prolonged/shortened QT Not so-BER inferior-lateral j-point elevation Catecholaminergic Polymorphic Ventricular
Tachycardia: Normal RESTING EKG/ECHO with recurrent syncope starting in childhood related to exertion/emotions.
EKG findings in Sentinel Death Events Myocarditis (diffuse flipped T waves) Congenital coronary-artery anomalies (large p waves) Coronary artery disease: (Wellen’s Sign, Hyperacute T
waves, Too tall T-waves) Valvular disorders (AS: LVH; MVP: normal or flipped T
waves inferiorly)
Heart racing, I feel ok now…
WPW Delta waves, short PR interval tall R-waves in V1, RBBB pattern Pseudoinfarction pattern inferiorly
Fainted…
Prolonged qt interval
Prolonged QT
QT interval
Depending on the rate, ~normally about the size of two big blocks
Woozy, I feel ok now…
Congenital SHORT QT syndrome (<320ms) --- vtach, syncope, SCD
Weekend warrior, passed out
Hypertrophic CardioMyopathy The most common ECG abnormalities
left ventricular hypertrophy abnormal ST-segments
Deeply flipped T-wave, tall R apical leads, deep Q waves laterally
Hypertrophic CardioMyopathy Asymmetrical thickening of the ventricular septum Patients may experience syncope, angina,
palpitations, dyspnea
Chief Complaint: Palpitations
Restrictive cardiomyopathy:
Low Voltage with flipped anterior Twaves
Restrictive cardiomyopathy:
Amyloidosis, sarcoidosis, hemochromatosis, etc Ventricles become rigid and lack the flexibility to expand during diastole. SOB, fatigue, palpitations & syncope
other common findings : atrial fib, conduction delays
Specific causes of non-specific flipped T-Waves
CAD/ischemia Cardiomyopathies Myocarditis, pericarditis PE Valvular disorders CNS bleed
LVH, BBB, paced
The eye does not see what the mind does not know...
Seizure vs. syncope…
Brugada
Na ion channelopathy that predisposes to v-tach/fib
Coved or Saddle types
Almost passed out, I feel ok now…
Arrhythmogenic Right Ventricular Dysplasia/ Cardiomyopathy• Replacement of RV muscle by fibro-fatty tissue• Associated with VT and ventricular fibrillation
Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy AVRD/C
May have Epsilon waves: sharp discrete deflections at the terminal portion of the QRS complex in V1-2
Inverted T waves in the anterior leads Incomplete or complete RBBB
Blips or wiggles in the terminal part of the QRS
Passed out, I feel better now…
BER vs Not-so-Benign Early Repolarization
Classically BER is found in the mid- precordial leads Notching, smiley face upward deflection Not-so BER: NEJM 358:2016-2023 Haïssaguerre et al, showed that
inferior-lateral ST elevation was associated with v tach/fib.
BER, with inferior-lateral J point elevation
• Similar j point elevation & notching has been noted in ARVD, WPW & Brugada.
• The jury is still out: BER in the inferior-lateral leads can be considered benign, unless the patient presents with syncope, palpitations, family hx sudden death.
Is it Syncope--
Cardiomyopathies Dilated Hypertrophic Restrictive ARVD/C Arrhythmogenic Right
Ventricular Dyplasia/Cardiomyopathy Primary arrhythmic syndromes
WPW QT intervalopathies Brugada ARVD CPVT Catecholaminergic Polymorphic
Ventricular Tachycardia Not-so BER
Other Biggies MI Pulmonary
Embolism
or is it a sentinel death event??
EKG in Chest Pain and/or SOB
• Ischemia
• Pericarditis/Myocarditis
• PE
• Tamponade
Passed out, I feel ok now…
PE S1,Q3,T3 Rt strain (RBBB pattern) Flipped anterior t-waves
Dogma: The most common ECG abnormalities in PE are tachycardia and nonspecific T wave abnormalities.
Recent studies: The most common ECG finding in PE is anterior T-wave inversion.
Mattu: the combination of flipped t-waves anteriorly and inferiorly is very specific for PE.
Flipped T waves in Pulmonary Embolism
Number of Leads with T Wave inversion correlating with RV dysfunction on Echo: ≤ 3 = 47% 4-6 = 92% ≥ 7 = 100%
Kosuge et al. Circ J 2006
Severe Shortness of breath
Tamponade
Low voltage: qrs <10mm precordial Obese patient The New Orleans’ Special
Restrictive cardiomyopathy Pericardial effusion Hypothyroid Hypothermia Myocarditis
I had chest pain, but I am ok now…
Wellen’s Sign• Associated with a critical, proximal LAD lesion
• Classically, occurs during a pain-free period
Chest Pain
HyperAcute T-waves HyperAcute T-waves in the anterior leads
Poor R- wave progression T-waves are asymmetrical and broad-based Follows a pattern of injury
Differential Diagnosis: Tall t-waves Hyperacute T-waves (broad, asym) HyperKalemia (narrow, pointy) BER (usually associated with tall r-waves) LVH (usually assoc with prwp) LBBB (prwp, wide)
I had chest pain, but I am ok now…
Today
One weekago
HyperAcute T-wave in V1The normal ECG has a small, flat or inverted T-wave in lead V1 and if
upright or larger in V1 than V6 in the setting of ACS: Suggests significant underlying CAD or acute ischemia if new
may precede other expected ECG changes Tall t-waves don’t belong in V1 except:
LBBB LVH
Chest Pain
ST elevation in V1, plus ST elevation AVR
AVR & Left Main lesions:is it magic or is it simply reversal of V6?
Fu, et al, The American Journal of Cardiology, Volume 99, Issue 7 reported higher mortality risk in patients with flipped T & ST depression in the V5-6.
Mattu: aVR
A. ST-segment elevation in lead aVR suggestive of LMCA occlusion: in NonSTEACS pts, increased 30 day mortality: Yan, American Heart Journal - Volume 154, Issue 1 B. PR-segment elevation suggestive of acute pericarditis. C. Prominent R′ wave suggestive of TCA poisoning.D. Rapid, regular, narrow QRS complex tachycardia with ST-segment elevation suggestive of WPW-related tachycardia.
I had chest pain, but I am ok now…
Pericarditis
CP, SOB…
25yo, low grade fever, dyspnea, uri symptoms, chest pain…
Myocarditis: SOB, CP, fever Diffuse T-wave inversions with or without ST segment abnormality
Incomplete atrioventricular conduction blocks or Intraventricular conduction blocks (usually transient)
EKG in Chest Pain and/or SOB
• Ischemia
• Pericarditis/Myocarditis
• PE
•Tamponade
EKG in Weak & DizzyElectrolytes
I feel weak…
Hyperkalemia
“SLOW Vtach”? It ain’t tach, if it ain’t tachyV-tach >120bpm….
• Severe hyperkalemia• Idioventricular/reperfusion dysrhythmias
• Type IA medication toxicity TCA toxicity Cocaine toxicity
I feel weak…
Hypocalcemia– prolonged QT
EKG in Weak & Dizzy Electrolytes
EKG in Overdose Na Channel Blockade
Widen QRS K+ efflux blocker
Prolongs qt interval AV nodal blocker
Depresses inotropy Depresses chronotropy
Digitalis: Na/K pump AV nodal blockage Increased automaticity
Depressed, AMS…
TCA overdose
Sodium channel blockade: TCA, Cocaine, Benadryl, anticholinergic, dilantinSALT: shock, AMS, Long QT & Terminal slurring R in AVR
Sympathetomimetics/Cocaine
Typically more tachy than TCA OD b/c less potassium efflux blockade
Depressed, took something….
Potassium efflux blockers: Medication induced long qt
Medication induced long qt
Depressed, AMS…
B-blocker/Ca-Channel blocker
DigitalisAcute: AV block
Chronic: Increased automaticity
EKG in Overdose TCA Sympathetomimetics/Cocaine B-blocker/Ca-Channel blocker Digitalis
EKG Stat!!
ECG, Willem Einthoven, assigning P, Q, R, S and T to the various deflections and awarded the 1924 Nobel Prize