Top Ten (or 11) EKG Killers

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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.

• Dont 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/ischemia
• HyperKalemia
• BER
• LVH, BBB,
• Paced

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Low voltage qrs lt10mm 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.

• Dont 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--
or is it a sentinel death event??

• 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

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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

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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 (Wellens 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 (lt320ms) --- 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 3582016-2023 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--
or is it a sentinel death event??

• 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

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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 lt10mm 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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Wellens 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 week ago
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HyperAcute T-wave in V1

• The 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 dont 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 lesionsis 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 Dizzy

• Electrolytes

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I feel weak
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Hyperkalemia
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SLOW Vtach?

• It aint tach, if it aint tachy
• V-tach gt120bpm.
• 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, dilantin SALT 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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Digitalis

• Acute 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