ECG Case StudiesECG Case Studies

Moosa KallaMoosa Kalla

Case 1Case 1

• 52 yr old man52 yr old man

• No Hx of IHDNo Hx of IHD

• Known HPT on RxKnown HPT on Rx

• Presents with acute onset chestPresents with acute onset chest

• Initial ECG normalInitial ECG normal

• Cardiac enzymes normalCardiac enzymes normal

• Admitted for observationsAdmitted for observations

ECG 24 Hrs post admissionECG 24 Hrs post admission

ECG findings

• Rate: 50• Rythym: sinus• PRI: normal• QRS: <0.12• : Rwave progression normal• ST seg: biphasic Twaves V2-V5• slight STE V1• No Q waves• AVR normal

Coronary angiogramCoronary angiogram

ManagementManagement

• Diagnosed with Wellen’s SyndromeDiagnosed with Wellen’s Syndrome

• Coronary angiogram showed 95% Coronary angiogram showed 95% stenosis of LADstenosis of LAD

• Percutaneous angioplasty and stinting Percutaneous angioplasty and stinting performedperformed

• Patient discharged 3 days laterPatient discharged 3 days later

Wellen’s SyndromeWellen’s Syndrome

• 1982 Wellen’s et al first published ECG criteria 1982 Wellen’s et al first published ECG criteria for subgroup of pt. with AMIfor subgroup of pt. with AMI

• Later came to be known as Wellen’s syndromeLater came to be known as Wellen’s syndrome• Wellen’s syndrome is a pre-infarction stage of Wellen’s syndrome is a pre-infarction stage of

coronary artery diseasecoronary artery disease• Recognition of this ECG pattern allows Recognition of this ECG pattern allows

identification of pt with severe LAD disease and identification of pt with severe LAD disease and hence at risk of anterior wall MIhence at risk of anterior wall MI

Charecteristics of Wellen’s SxCharecteristics of Wellen’s Sx

• Charecterised by Bi-phasic or T wave Charecterised by Bi-phasic or T wave inversion in precordial leadsinversion in precordial leads

• Typically caused by critical stenosis in Typically caused by critical stenosis in proximal LADproximal LAD

• The charecteristic ECG pattern often The charecteristic ECG pattern often develops while pt is pain freedevelops while pt is pain free

• During chest pain ST-segemnet-T-wave During chest pain ST-segemnet-T-wave abnormalities normalize or develop into abnormalities normalize or develop into ST-segment elevationST-segment elevation

Case 2Case 2

• 28 year old man c/o lightheadedness and 28 year old man c/o lightheadedness and shortness of breath,than collapsesshortness of breath,than collapses

• On scene is PEA,On scene is PEA,

• CPR instituted and intubatedCPR instituted and intubated

• Arrives in ED 15min post collapseArrives in ED 15min post collapse

• ECG showed fine VFECG showed fine VF

• Defib at 200J and ECG redone at 2minDefib at 200J and ECG redone at 2min

ECG at 2 minECG at 2 min

ECG FINDINGSECG FINDINGS

• Rate: 75Rate: 75

• Rhythm: sinusRhythm: sinus

• PRI: normalPRI: normal

• Axis: normalAxis: normal

• QRS:RSR V1 V2, Incomplete RBBBQRS:RSR V1 V2, Incomplete RBBB

• ST elevation V1 V2, downslopingST elevation V1 V2, downsloping

Brugada syndromeBrugada syndrome

• Described by Brugada and Pedro 1992Described by Brugada and Pedro 1992• Frequent cause of death in pt. with normal heartsFrequent cause of death in pt. with normal hearts• Also a cause of sudden death in athletic Also a cause of sudden death in athletic

populationpopulation• More frequently diagnosed in males of South East More frequently diagnosed in males of South East

Asian descentAsian descent• Charecterised by ECG abnormalities in V1 to V3: Charecterised by ECG abnormalities in V1 to V3:

i ) incomplete RBBBi ) incomplete RBBB• ii) ST segment elevation ii) ST segment elevation

• ) Caused by a reduction of sodium current across ) Caused by a reduction of sodium current across cardiac sodium channelscardiac sodium channels

• ST elevation thought to be due to rebalancing of currents ST elevation thought to be due to rebalancing of currents active at end of phase 1 active at end of phase 1

• Definitive treatment is by placement of Internal Cardio-Definitive treatment is by placement of Internal Cardio-defibrilator(ICD )defibrilator(ICD )

• Mortality at 10yrs is 0%for ICD and 26% for Mortality at 10yrs is 0%for ICD and 26% for pharmocological agents(amiodorone,pharmocological agents(amiodorone,BB-blockers Mortality -blockers Mortality at 10yrs is 0%for ICD and 26% for pharmocological at 10yrs is 0%for ICD and 26% for pharmocological agents(amiodorone,agents(amiodorone,BB-blockers -blockers

Case 3Case 3

• 40yr old man, 2d HX intermittent chest pain40yr old man, 2d HX intermittent chest pain• Hx of smoking, hyperlipidaemia and PUDHx of smoking, hyperlipidaemia and PUD• O/E T 37.5 BP 140/80 P100O/E T 37.5 BP 140/80 P100• Heart sounds distant ,no cardiac or pleural rubsHeart sounds distant ,no cardiac or pleural rubs• ECHO and CXR normalECHO and CXR normal

ECGECG

ECG FindingsECG Findings

• Rate:140Rate:140• Rythym: sinusRythym: sinus• PRI: normalPRI: normal• PR seg: elevation aVR, PR seg: elevation aVR, • : depression ii V5 V6: depression ii V5 V6• Axis: normalAxis: normal• QRS: <.012QRS: <.012• ST seg: concave STE I II III V4-V6ST seg: concave STE I II III V4-V6• No reciprical changesNo reciprical changes

LAB findingsLAB findings

• Trop t negativeTrop t negative

• WCC 12.5WCC 12.5

• ESR 50ESR 50

• Urgent angiography showed healthy Urgent angiography showed healthy coronary arteriescoronary arteries

PericarditisPericarditis

• Pericarditis syndrome caused by inflamation of Pericarditis syndrome caused by inflamation of pericardium pericardium

• There is increased vascular permeability, There is increased vascular permeability, vasodilation and transudationvasodilation and transudation

• Patient presents with sharp central chest pain Patient presents with sharp central chest pain worse with inspiration and recumbencyworse with inspiration and recumbency

• Pain may radiatePain may radiate

CausesCauses

..

• O/E pericardial friction rub is a pathognomic finding,best O/E pericardial friction rub is a pathognomic finding,best heard in expiration,heard 50% of timesheard in expiration,heard 50% of times

• Distinct ECG findings:Distinct ECG findings:• i) Concave ST elevationi) Concave ST elevation• ii) PR seg depressionii) PR seg depression• iii) widespread STE not corresponding to any arterial iii) widespread STE not corresponding to any arterial

territoryterritory• iv) Absence of reciprocal changes and Q wavesiv) Absence of reciprocal changes and Q waves• v) Possible presecnce of low voltagesv) Possible presecnce of low voltages• (STE II>STE III strongly favours acute pericarditis;STE (STE II>STE III strongly favours acute pericarditis;STE

III>STE II strongly favours AMIIII>STE II strongly favours AMI

Differential diagnosisDifferential diagnosis

Stages in ECG changesStages in ECG changes

Case 4Case 4

• 58 yr old man, 45min severe chest pain58 yr old man, 45min severe chest pain• Grey sweaty,nauseous,SOB,anxiousGrey sweaty,nauseous,SOB,anxious• Clinically RR 16 BP 135/75 P 75Clinically RR 16 BP 135/75 P 75• Heart sounds normal, no mumursHeart sounds normal, no mumurs

ECGECG

ECGECG

• Rate: 80Rate: 80

• Rythym: sinusRythym: sinus

• PR: normalPR: normal

• QRS: LBBBQRS: LBBB

• ST seg: global discordanceST seg: global discordance

• : concordance V4 1 mm: concordance V4 1 mm

Sgarbossa criteriaSgarbossa criteria

• LBB on ECG may mask changes of AMILBB on ECG may mask changes of AMI• Can delay reognition of AMI and thrombolysisCan delay reognition of AMI and thrombolysis• Sgarbossa et al tested criteria for AMI in Sgarbossa et al tested criteria for AMI in

presence of LBBBpresence of LBBB• Data used from patients enrolled on GUSTO-1 Data used from patients enrolled on GUSTO-1

trialtrial• These patients had AMI confirmed by enzyme These patients had AMI confirmed by enzyme

studiesstudies

Criteria analysedCriteria analysed

FindingsFindings

• ST segment deviations only ECG findings ST segment deviations only ECG findings useful in diagnosisng acute myocardal useful in diagnosisng acute myocardal infarction in the presence of LBBBinfarction in the presence of LBBB

Criteria selectedCriteria selected

•The ST changes that were significant are:The ST changes that were significant are:1.ST elevation > or = 1mm and concordant 1.ST elevation > or = 1mm and concordant with QRS.with QRS.2.ST depression > or = 1mm in v1,v2 or 2.ST depression > or = 1mm in v1,v2 or v3.v3.3.ST elevation > or = 5mm and discordant 3.ST elevation > or = 5mm and discordant with QRS.with QRS.

Concept of Con/discordance

• Refers to whether the last portion of the QRS complex goes in the same or opposite direction to the T wave

• Discordance=opposite=good= secondary

• Concordance= same=bad=primary

ECG 5

• Elderly lady,far-east origin

• New onset chest pain

• Nausea and diaphoresis

• Recent severe social stressors

ED ECGED ECG

Hospital course

• Emergency cardiac catherisatrion… no obstructive coronary artery disease

• Patient had haemodynamic profile of cardiogenic shock:

• intra-aortic balloon pump

• started on vasopressor support

ECG 24 Hrs LaterECG 24 Hrs Later

ECHO findings at 24 hours

• Moderate to severe systolic dysfunction of LV which is segmental

• Only proximal segment of IV septum and anterolateral wall contracting normally

• Ballooning of distal ventricle• EF estimated at 20%• Consistent findings of Taka-Tsubo

syndrome• Moderate mitral regurgitation

Ecg at 36 HrsEcg at 36 Hrs

ECG Findings

• Rate: 100• Rythym: sinus• PRI: normal• Axis: left• QRS: narrow• ST seg: STE V-V5• : biphasic V3-V5• : inverted V6

Tokatsubo CardiomyopathyTokatsubo Cardiomyopathy

• Acute stress cardiomyopathy,described as form of Acute stress cardiomyopathy,described as form of Reversible Left Ventricular Systolic Dysfunction in the Reversible Left Ventricular Systolic Dysfunction in the absence of coronary artery diseaseabsence of coronary artery disease

• First described in JapanFirst described in Japan• Now global distributionNow global distribution• Also known as Broken Heart Syndrome (BHS)Also known as Broken Heart Syndrome (BHS)• Pathogenisis not well understoodPathogenisis not well understood

• More common in woman aged 62-7More common in woman aged 62-755

PresentationPresentation

• Typically triggered by emotional, physical or Typically triggered by emotional, physical or medical stressorsmedical stressors

• Commonly present with SOBCommonly present with SOB• ShockShock• ECG changes of ischaemiaECG changes of ischaemia

Postulated mechanismsPostulated mechanisms

• i) cathecholamine-induced induced vent i) cathecholamine-induced induced vent dysfunction(due to stress hormone dysfunction(due to stress hormone release)release)

• ii)multivessel coronary spasmii)multivessel coronary spasm

• iii) dynamic left vent outflow tract iii) dynamic left vent outflow tract obstructionobstruction

Distinguishing from ACSDistinguishing from ACS

• Features distinguishing SC from LAD Features distinguishing SC from LAD territory infarction are:territory infarction are:

• i) Abnormal ST elevation/depression, t wave i) Abnormal ST elevation/depression, t wave inversion, raerely Q wavesinversion, raerely Q waves

• ii) cardiac biomarkers mildly elevatedii) cardiac biomarkers mildly elevated• iii) wall motion abnormal on ECHO-large area for iii) wall motion abnormal on ECHO-large area for

single artery involvementsingle artery involvement• iv)Lack of delayed hyperenhancement on MRI iv)Lack of delayed hyperenhancement on MRI

with gadoliniumwith gadolinium

Clinical courseClinical course

• Recovery of baseline Left ventricular Recovery of baseline Left ventricular function within 1-4 weeksfunction within 1-4 weeks

• Low mortality ranging from 0-8%Low mortality ranging from 0-8%

• Diagnosis is mainly by exclusion of ACSDiagnosis is mainly by exclusion of ACS• NB NB suspicion of stress cardiomyopathy not sufficient suspicion of stress cardiomyopathy not sufficient

reason to withold treatment for acute ACS…stress reason to withold treatment for acute ACS…stress cardiomyopathy diagnosed by presence of all 4 criterai cardiomyopathy diagnosed by presence of all 4 criterai listed abovelisted above

1 more ECG

ECG findings

• Rate: 66

• Rythym: ventricular paced

• Axis: left

• QRS: LBBB

• :Q waves V1-V6

• ST seg: discordant all leads except V2

Baseline ECG at 10min

ECG

• Rate: 66• Rythym: sinus• Axis: normal• PRI normal• QRS: LBBB• ST seg: STE II III aVF• : reciprocal changes aVL and• V2

ManagementManagement

• Aspirin 300mgAspirin 300mg

• TNT 2 tabs STNT 2 tabs S

• Morphine 2.5mg IVIMorphine 2.5mg IVI

• GTN infusion commencedGTN infusion commenced

• Pain decreased from 8/10 to 6/10Pain decreased from 8/10 to 6/10

• Spontaneously reverted to native rythymSpontaneously reverted to native rythym

ManagementManagement

• Reteplase started 30 min after arrivalReteplase started 30 min after arrival• Had hypotensive episode,responded to 1000ml Had hypotensive episode,responded to 1000ml

N/SN/S• ST segment elevation decreasedST segment elevation decreased• Pain-free 35min after initial bolus(110min after Pain-free 35min after initial bolus(110min after

onset of pain)onset of pain)• Coronary angio at 36hrs showed tightly narrowed Coronary angio at 36hrs showed tightly narrowed

right coronary artery which was stentedright coronary artery which was stented• Had good LV functionHad good LV function

1 More

And more ECG’s

ReferencesReferences• 1 . A Faras Husain,A AbuZayed,Brugada syndrome causing Cardiac Arrest,Arab 1 . A Faras Husain,A AbuZayed,Brugada syndrome causing Cardiac Arrest,Arab

Health magazine,Issue three 2008, p22-23Health magazine,Issue three 2008, p22-23• 2. Glancy DL, Bahij K;Chest pain and LBBB;2. Glancy DL, Bahij K;Chest pain and LBBB;

BUMC Proceedings;Vol14 no 4,p452-454BUMC Proceedings;Vol14 no 4,p452-454

3.3. Karen marzlin;Clinical insights from unusual case studies in cardiovascular care:NIT Karen marzlin;Clinical insights from unusual case studies in cardiovascular care:NIT 2008; 2008; www.cardionursing.com

4.4. R Farah,E Nassier; The Brugada Syndrome:An easily identifiable and preventable R Farah,E Nassier; The Brugada Syndrome:An easily identifiable and preventable cause of sudden cardiac death;Israeli Journal of Emergency Medicine;Vol 6,no1 Feb cause of sudden cardiac death;Israeli Journal of Emergency Medicine;Vol 6,no1 Feb 20062006

5.5. J Knott;Diagnosis of acute myocardial infarction with ventricular paced J Knott;Diagnosis of acute myocardial infarction with ventricular paced rythym;Emergency Medicine 2003 15 (100-103)rythym;Emergency Medicine 2003 15 (100-103)

6.6. HC CHEW,SH LIM; ECG case.ST Elevation:Is this an infarct?; Singapore med HC CHEW,SH LIM; ECG case.ST Elevation:Is this an infarct?; Singapore med Journal; 2005 46 (11): 656Journal; 2005 46 (11): 656

7.7. A De Meester et al; Symptomatic pericarditis after influenza vaccine . CHESTT / A De Meester et al; Symptomatic pericarditis after influenza vaccine . CHESTT / 117/6 June 200 p 1803-1805117/6 June 200 p 1803-1805

8.8. A Mattu,W Braddy; ECG’s for the Emergency Physician, BMJ 2003A Mattu,W Braddy; ECG’s for the Emergency Physician, BMJ 2003