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