Download ECG Case Studies

ECG Case Studies
Moosa Kalla
Case 1
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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
ECG 24 Hrs post admission
ECG findings
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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 angiogram
Management
• Diagnosed with Wellen’s Syndrome
• Coronary angiogram showed 95%
stenosis of LAD
• Percutaneous angioplasty and stinting
performed
• Patient discharged 3 days later
Wellen’s Syndrome
• 1982 Wellen’s et al first published ECG criteria
for subgroup of pt. with AMI
• Later came to be known as Wellen’s syndrome
• Wellen’s 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
Charecteristics of Wellen’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
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
ECG at 2 min
ECG FINDINGS
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Rate: 75
Rhythm: sinus
PRI: normal
Axis: normal
QRS:RSR V1 V2, Incomplete RBBB
ST elevation V1 V2, downsloping
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
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ii) ST segment elevation
• ) 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 Cardiodefibrilator(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
Case 3
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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
ECG
ECG Findings
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Rate:140
Rythym: sinus
PRI: normal
PR seg: elevation aVR,
: depression ii V5 V6
Axis: normal
QRS: <.012
ST seg: concave STE I II III V4-V6
No reciprical changes
LAB findings
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Trop t negative
WCC 12.5
ESR 50
Urgent angiography showed healthy
coronary arteries
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
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 II>STE III strongly favours acute pericarditis;STE
III>STE II strongly favours AMI
Differential diagnosis
Stages in ECG changes
Case 4
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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
ECG
ECG
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Rate: 80
Rythym: sinus
PR: normal
QRS: LBBB
ST seg: global discordance
: concordance V4 1 mm
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
Criteria analysed
Findings
• ST segment deviations only ECG findings
useful in diagnosisng acute myocardal
infarction in the presence of LBBB
Criteria selected
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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.
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
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Elderly lady,far-east origin
New onset chest pain
Nausea and diaphoresis
Recent severe social stressors
ED 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 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 Hrs
ECG Findings
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Rate: 100
Rythym: sinus
PRI: normal
Axis: left
QRS: narrow
ST seg: STE V-V5
: biphasic V3-V5
: inverted V6
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
Presentation
• Typically triggered by emotional, physical or
medical stressors
• Commonly present with SOB
• Shock
• ECG changes of ischaemia
Postulated mechanisms
• i) cathecholamine-induced induced vent
dysfunction(due to stress hormone
release)
• ii)multivessel coronary spasm
• iii) dynamic left vent outflow tract
obstruction
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
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 all 4 criterai
listed above
1 more ECG
ECG findings
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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
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Rate: 66
Rythym: sinus
Axis: normal
PRI normal
QRS: LBBB
ST seg: STE II III aVF
: reciprocal changes aVL and
V2
Management
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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
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
1 More
And more ECG’s
References
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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,p452-454
3. 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