Top Ten (or 11) EKG Killers

1. Top Ten (or 11) EKG Killers Micelle Haydel, MD LSUHSC New Orleans

2. 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

3. The EKG must be interpreted in the clinical context. • Don’t order a test unless you know what to do with the results…

4. 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 The Normal Adult EKG

5. 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)

6. Specific causes of non-specificflipped T-Waves • CAD/ischemia • Cardiomyopathies • Myocarditis, pericarditis • PE • Valvular disorders • CNS bleed • LVH, BBB, paced

7. Differential Diagnosis: Tall t-waves • Hyperacute T-waves/ischemia • HyperKalemia • BER • LVH, BBB, Paced

8. Low voltage: qrs <10mm precordial • Obese patient The New Orleans’ Special • Restrictive cardiomyopathy • Pericardial effusion • Hypothyroid • Hypothermia • Myocarditis

9. The EKG must be interpreted in the clinical context. • Don’t order a test unless you know what to do with the results…

10. EKG in Syncope, PreSyncope, Palpitations

11. 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 Is it Syncope-- or is it a sentinel death event??

12. ~300,000/yr in US Over 35 years ~80% due to CAD ~15% Cardiomyopathy NEJM Huikuri et al. 345 (20): 1473,  November 15, 2001 Sudden Cardiac Death: unexpected death within 1 hour of symptomsFinal, common pathway: Vtach/fib 90%

13. 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

14. 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)

15. 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. EKG findings in Sentinel Death Events

16. EKG findings in Sentinel Death Events • Myocarditis (diffuse flipped T waves) • Congenital coronary-artery anomalies (large p waves) • Coronary artery disease: (Wellen’s Sign, Hyperacute T waves, Too tall T-waves) • Valvular disorders (AS: LVH; MVP: normal or flipped T waves inferiorly)

17. Heart racing, I feel ok now…

18. WPW • Delta waves, short PR interval • tall R-waves in V1, RBBB pattern • Pseudoinfarction pattern inferiorly

19. Fainted…

20. Prolonged qt interval

21. Prolonged QT

22. QT interval • Depending on the rate, ~normally about the size of two big blocks

23. Woozy, I feel ok now…

24. Congenital SHORT QT syndrome (<320ms) --- vtach, syncope, SCD

25. Weekend warrior, passed out

26. 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

27. Hypertrophic CardioMyopathy • Asymmetrical thickening of the ventricular septum • Patients may experience syncope, angina, palpitations, dyspnea

28. Chief Complaint: Palpitations

29. Restrictive cardiomyopathy: Low Voltage with flipped anterior Twaves

30. 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

31. Specific causes of non-specificflipped T-Waves • CAD/ischemia • Cardiomyopathies • Myocarditis, pericarditis • PE • Valvular disorders • CNS bleed • LVH, BBB, paced

32. The eye does not see what the mind does not know...

33. Seizure vs. syncope…

34. Brugada Na ion channelopathy that predisposes to v-tach/fib Coved or Saddle types

35. Almost passed out, I feel ok now…

36. Arrhythmogenic Right Ventricular Dysplasia/ Cardiomyopathy • Replacement of RV muscle by fibro-fatty tissue • Associated with VT and ventricular fibrillation

37. 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

38. Passed out, I feel better now…

39. Classically BER is found in the mid- precordial leads Notching, smiley face upward deflection Not-so BER: NEJM 358:2016-2023 Haïssaguerre et al, showed that inferior-lateral ST elevation was associated with v tach/fib. BER vs Not-so-Benign Early Repolarization

40. 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.

41. 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 Is it Syncope-- or is it a sentinel death event??

42. EKG in Chest Pain and/or SOB • Ischemia • Pericarditis/Myocarditis • PE • Tamponade

43. Passed out, I feel ok now…

44. PE • S1,Q3,T3 • Rt strain (RBBB pattern) • Flipped anterior t-waves

45. 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.

46. 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 Flipped T waves in Pulmonary Embolism

47. Severe Shortness of breath

48. Tamponade

49. Low voltage: qrs <10mm precordial • Obese patient The New Orleans’ Special • Restrictive cardiomyopathy • Pericardial effusion • Hypothyroid • Hypothermia • Myocarditis

50. I had chest pain, but I am ok now…