ECG Case Studies

ECG Case Studies Moosa Kalla

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Case 1 • 52 yr old man• No Hx of IHD• Known HPT on Rx• Presents with acute onset chest• Initial ECG normal• Cardiac enzymes normal• Admitted for observations

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ECG 24 Hrs post admission

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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

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Coronary angiogram

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Management • Diagnosed with Wellen’s Syndrome• Coronary angiogram showed 95% stenosis of LAD • Percutaneous angioplasty and stinting performed • Patient discharged 3 days later

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Wel en’s Syndrome • 1982 Wel en’s et al first published ECG criteria for subgroup of pt. with AMI • Later came to be known as Wel en’s syndrome• Wel en’s syndrome is a pre-infarction stage of coronary artery disease • Recognition of this ECG pattern al ows identification of pt with severe LAD disease and hence at risk of anterior wal MI

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Charecteristics of Wel en’s Sx • Charecterised by Bi-phasic or T wave inversion in precordial leads • Typically caused by critical stenosis in proximal LAD • The charecteristic ECG pattern often develops while pt is pain free • During chest pain ST-segemnet-T-wave abnormalities normalize or develop into ST-segment elevation

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Case 2 • 28 year old man c/o lightheadedness and shortness of breath,than collapses • On scene is PEA,• CPR instituted and intubated• Arrives in ED 15min post collapse• ECG showed fine VF• Defib at 200J and ECG redone at 2min

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ECG at 2 min

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ECG FINDINGS • Rate: 75• Rhythm: sinus• PRI: normal• Axis: normal• QRS:RSR V1 V2, Incomplete RBBB• ST elevation V1 V2, downsloping

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Brugada syndrome • Described by Brugada and Pedro 1992• Frequent cause of death in pt. with normal hearts• Also a cause of sudden death in athletic population • More frequently diagnosed in males of South East Asian descent • Charecterised by ECG abnormalities in V1 to V3: i ) incomplete RBBB • i ) ST segment elevation

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• ) Caused by a reduction of sodium current across cardiac sodium channels • ST elevation thought to be due to rebalancing of currents active at end of phase 1 • Definitive treatment is by placement of Internal Cardio- defibrilator(ICD ) • Mortality at 10yrs is 0%for ICD and 26% for pharmocological agents(amiodorone,B-blockers Mortality at 10yrs is 0%for ICD and 26% for pharmocological agents(amiodorone,B-blockers

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Case 3 • 40yr old man, 2d HX intermittent chest pain• Hx of smoking, hyperlipidaemia and PUD• O/E T 37.5 BP 140/80 P100• Heart sounds distant ,no cardiac or pleural rubs• ECHO and CXR normal

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ECG

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ECG Findings • Rate:140• Rythym: sinus• PRI: normal• PR seg: elevation aVR, • : depression i V5 V6• Axis: normal• QRS: <.012• ST seg: concave STE I II III V4-V6• No reciprical changes

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LAB findings • Trop t negative• WCC 12.5• ESR 50• Urgent angiography showed healthy coronary arteries

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Pericarditis • Pericarditis syndrome caused by inflamation of pericardium • There is increased vascular permeability, vasodilation and transudation • Patient presents with sharp central chest pain worse with inspiration and recumbency • Pain may radiate

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Causes

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. • O/E pericardial friction rub is a pathognomic finding,best heard in expiration,heard 50% of times • Distinct ECG findings:• i) Concave ST elevation• i ) PR seg depression• i i) widespread STE not corresponding to any arterial territory • iv) Absence of reciprocal changes and Q waves• v) Possible presecnce of low voltages• (STE II>STE III strongly favours acute pericarditis;STE III>STE II strongly favours AMI

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Differential diagnosis

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Stages in ECG changes

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Case 4 • 58 yr old man, 45min severe chest pain• Grey sweaty,nauseous,SOB,anxious• Clinical y RR 16 BP 135/75 P 75• Heart sounds normal, no mumurs

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ECG

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ECG • Rate: 80• Rythym: sinus• PR: normal• QRS: LBBB• ST seg: global discordance• : concordance V4 1 mm

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Sgarbossa criteria • LBB on ECG may mask changes of AMI• Can delay reognition of AMI and thrombolysis• Sgarbossa et al tested criteria for AMI in presence of LBBB • Data used from patients enrol ed on GUSTO-1 trial • These patients had AMI confirmed by enzyme studies

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Criteria analysed

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

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

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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

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ECG 5 • Elderly lady,far-east origin• New onset chest pain• Nausea and diaphoresis• Recent severe social stressors

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ED ECG

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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

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ECG 24 Hrs Later

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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

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Ecg at 36 Hrs

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

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Tokatsubo Cardiomyopathy • Acute stress cardiomyopathy,described as form of Reversible Left Ventricular Systolic Dysfunction in the absence of coronary artery disease • First described in Japan• Now global distribution• Also known as Broken Heart Syndrome (BHS)• Pathogenisis not wel understood• More common in woman aged 62-75

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Presentation • Typical y triggered by emotional, physical or medical stressors • Commonly present with SOB• Shock• ECG changes of ischaemia

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Postulated mechanisms • i) cathecholamine-induced induced vent dysfunction(due to stress hormone release) • ii)multivessel coronary spasm• iii) dynamic left vent outflow tract obstruction

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Distinguishing from ACS • Features distinguishing SC from LAD territory infarction are: • i) Abnormal ST elevation/depression, t wave inversion, raerely Q waves • i ) cardiac biomarkers mildly elevated• i i) wal motion abnormal on ECHO-large area for single artery involvement • iv)Lack of delayed hyperenhancement on MRI with gadolinium

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Clinical course • Recovery of baseline Left ventricular function within 1-4 weeks • Low mortality ranging from 0-8%• Diagnosis is mainly by exclusion of ACS• NB suspicion of stress cardiomyopathy not sufficient reason to withold treatment for acute ACS…stress cardiomyopathy diagnosed by presence of al 4 criterai listed above

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1 more ECG

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ECG findings • Rate: 66• Rythym: ventricular paced• Axis: left• QRS: LBBB• :Q waves V1-V6• ST seg: discordant all leads except V2

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Baseline ECG at 10min

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

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Management • Aspirin 300mg• TNT 2 tabs S• Morphine 2.5mg IVI• GTN infusion commenced• Pain decreased from 8/10 to 6/10• Spontaneously reverted to native rythym

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Management • Reteplase started 30 min after arrival• Had hypotensive episode,responded to 1000ml N/S • ST segment elevation decreased• Pain-free 35min after initial bolus(110min after onset of pain) • Coronary angio at 36hrs showed tightly narrowed right coronary artery which was stented • Had good LV function

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1 More

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And more ECG’s

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References • 1 . A Faras Husain,A AbuZayed,Brugada syndrome causing Cardiac Arrest,Arab Health magazine,Issue three 2008, p22-23 • 2. Glancy DL, Bahij K;Chest pain and LBBB; BUMC Proceedings;Vol14 no 4,p452-4543. Karen marzlin;Clinical insights from unusual case studies in cardiovascular care:NIT 2008; www.cardionursing.com 4. 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 2006 5. J Knott;Diagnosis of acute myocardial infarction with ventricular paced rythym;Emergency Medicine 2003 15 (100-103) 6. HC CHEW,SH LIM; ECG case.ST Elevation:Is this an infarct?; Singapore med Journal; 2005 46 (11): 656 7. A De Meester et al; Symptomatic pericarditis after influenza vaccine . CHESTT / 117/6 June 200 p 1803-1805 8. A Mattu,W Braddy; ECG’s for the Emergency Physician, BMJ 2003

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