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Top Ten (or 11) EKG Killers
Micelle Haydel, MD
LSUHSC New Orleans
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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
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The EKG must be interpreted in the clinical context.
Don’t order a test unless you know what to do with the results…
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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
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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)
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Specific causes of non-specific flipped T-Waves
CAD/ischemia Cardiomyopathies Myocarditis, pericarditis PE Valvular disorders CNS bleed
LVH, BBB, paced
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Differential Diagnosis: Tall t-waves
Hyperacute T-waves/ischemiaHyperKalemia
BER LVH, BBB,
Paced
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Low voltage: qrs <10mm precordial
Obese patient The New Orleans’ Special
Restrictive cardiomyopathy Pericardial effusion Hypothyroid Hypothermia Myocarditis
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The EKG must be interpreted in the clinical context.
Don’t order a test unless you know what to do with the results…
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EKG in Syncope, PreSyncope, Palpitations
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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??
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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
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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
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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)
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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.
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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)
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Heart racing, I feel ok now…
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WPW Delta waves, short PR interval tall R-waves in V1, RBBB pattern Pseudoinfarction pattern inferiorly
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Fainted…
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Prolonged qt interval
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Prolonged QT
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QT interval
Depending on the rate, ~normally about the size of two big blocks
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Woozy, I feel ok now…
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Congenital SHORT QT syndrome (<320ms) --- vtach, syncope, SCD
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Weekend warrior, passed out
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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
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Hypertrophic CardioMyopathy Asymmetrical thickening of the ventricular septum Patients may experience syncope, angina,
palpitations, dyspnea
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Chief Complaint: Palpitations
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Restrictive cardiomyopathy:
Low Voltage with flipped anterior Twaves
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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
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Specific causes of non-specific flipped T-Waves
CAD/ischemia Cardiomyopathies Myocarditis, pericarditis PE Valvular disorders CNS bleed
LVH, BBB, paced
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The eye does not see what the mind does not know...
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Seizure vs. syncope…
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Brugada
Na ion channelopathy that predisposes to v-tach/fib
Coved or Saddle types
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Almost passed out, I feel ok now…
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Arrhythmogenic Right Ventricular Dysplasia/ Cardiomyopathy• Replacement of RV muscle by fibro-fatty tissue• Associated with VT and ventricular fibrillation
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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
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Passed out, I feel better now…
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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.
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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.
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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??
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EKG in Chest Pain and/or SOB
• Ischemia
• Pericarditis/Myocarditis
• PE
• Tamponade
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Passed out, I feel ok now…
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PE S1,Q3,T3 Rt strain (RBBB pattern) Flipped anterior t-waves
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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.
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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
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Severe Shortness of breath
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Tamponade
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Low voltage: qrs <10mm precordial Obese patient The New Orleans’ Special
Restrictive cardiomyopathy Pericardial effusion Hypothyroid Hypothermia Myocarditis
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I had chest pain, but I am ok now…
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Wellen’s Sign• Associated with a critical, proximal LAD lesion
• Classically, occurs during a pain-free period
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Chest Pain
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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
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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)
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I had chest pain, but I am ok now…
Today
One weekago
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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
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Chest Pain
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ST elevation in V1, plus ST elevation AVR
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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.
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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.
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I had chest pain, but I am ok now…
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Pericarditis
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CP, SOB…
25yo, low grade fever, dyspnea, uri symptoms, chest pain…
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Myocarditis: SOB, CP, fever Diffuse T-wave inversions with or without ST segment abnormality
Incomplete atrioventricular conduction blocks or Intraventricular conduction blocks (usually transient)
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EKG in Chest Pain and/or SOB
• Ischemia
• Pericarditis/Myocarditis
• PE
•Tamponade
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EKG in Weak & DizzyElectrolytes
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I feel weak…
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Hyperkalemia
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“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
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I feel weak…
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Hypocalcemia– prolonged QT
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EKG in Weak & Dizzy Electrolytes
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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
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Depressed, AMS…
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TCA overdose
Sodium channel blockade: TCA, Cocaine, Benadryl, anticholinergic, dilantinSALT: shock, AMS, Long QT & Terminal slurring R in AVR
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Sympathetomimetics/Cocaine
Typically more tachy than TCA OD b/c less potassium efflux blockade
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Depressed, took something….
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Potassium efflux blockers: Medication induced long qt
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Medication induced long qt
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Depressed, AMS…
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B-blocker/Ca-Channel blocker
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DigitalisAcute: AV block
Chronic: Increased automaticity
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EKG in Overdose TCA Sympathetomimetics/Cocaine B-blocker/Ca-Channel blocker Digitalis
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EKG Stat!!
ECG, Willem Einthoven, assigning P, Q, R, S and T to the various deflections and awarded the 1924 Nobel Prize