ECG Case Studies

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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 lt0.12
• 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 Wellens Syndrome
• Coronary angiogram showed 95 stenosis of LAD
• Percutaneous angioplasty and stinting performed
• Patient discharged 3 days later

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Wellens Syndrome

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

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Charecteristics of Wellens 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
• QRSRSR 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
• ii) 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 0for ICD and 26 for
  pharmocological agents(amiodorone,B-blockers
  Mortality at 10yrs is 0for 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

• Rate140
• Rythym sinus
• PRI normal
• PR seg elevation aVR,
• depression ii V5 V6
• Axis normal
• QRS lt.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
• ii) PR seg depression
• iii) widespread STE not corresponding to any
  arterial territory
• iv) Absence of reciprocal changes and Q waves
• v) Possible presecnce of low voltages
• (STE IIgtSTE III strongly favours acute
  pericarditisSTE IIIgtSTE 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
• Clinically 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 enrolled 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 are1.ST
  elevation gt or 1mm and concordant with
  QRS.2.ST depression gt or 1mm in v1,v2 or
  v3.3.ST elevation gt 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
• Discordanceoppositegood secondary
• Concordance samebadprimary

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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 well understood
• More common in woman aged 62-75

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Presentation

• Typically 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
• ii) cardiac biomarkers mildly elevated
• iii) wall 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
  ACSstress cardiomyopathy diagnosed by presence
  of all 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 ECGs
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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 KChest pain and LBBB
• BUMC ProceedingsVol14 no 4,p452-454
• Karen marzlinClinical insights from unusual case
  studies in cardiovascular careNIT 2008
  www.cardionursing.com
• R Farah,E Nassier The Brugada SyndromeAn easily
  identifiable and preventable cause of sudden
  cardiac deathIsraeli Journal of Emergency
  MedicineVol 6,no1 Feb 2006
• J KnottDiagnosis of acute myocardial infarction
  with ventricular paced rythymEmergency Medicine
  2003 15 (100-103)
• HC CHEW,SH LIM ECG case.ST ElevationIs this an
  infarct? Singapore med Journal 2005 46 (11)
  656
• A De Meester et al Symptomatic pericarditis
  after influenza vaccine . CHESTT / 117/6 June 200
  p 1803-1805
• A Mattu,W Braddy ECGs for the Emergency
  Physician, BMJ 2003