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EKG rounds

EKG rounds. Rebecca Burton-MacLeod R5, Emerg Med Dec 13 th , 2007. Case. 67y Caucasian F presents to ED c/o exertional SOB Worsening over last 8d No other assoc symptoms PMHx: HTN, DM, hyperlipidemia O/e: HR 88 BP 140/85 RR 20 sats 96% Nil acute on examination. Case cont’d.

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EKG rounds

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  1. EKG rounds Rebecca Burton-MacLeod R5, Emerg Med Dec 13th, 2007

  2. Case • 67y Caucasian F presents to ED c/o exertional SOB • Worsening over last 8d • No other assoc symptoms • PMHx: HTN, DM, hyperlipidemia • O/e: HR 88 BP 140/85 RR 20 sats 96% • Nil acute on examination

  3. Case cont’d • Any investigations? • PS. Don’t forget…this is “EKG rounds”…

  4. Presenting EKG

  5. Ddx T wave inversion… Am J Emerg Med. 2002.

  6. Case cont’d • Blwk: • TNT normal • D-dimer 3.27 • Investigations: • Echo: RV systolic dysfxn, mod-severe pulm hypertension • CT confirmed PE

  7. PE and EKG findings • Classic findings: • Sinus tachycardia • S1Q3T3 • Rt heart strain

  8. Why T inversion with PE ? • Possible mechanisms: • Due to acute cor pulmonale from RV enlargement and RV ischemia • Other factors such as hypoxemia and chemical mediator release in RV may lead to T wave inversion • T inversion occurs in 42-89% of acute PE cases

  9. N=80 pts hospitalized for PE • Analysis of admission EKG’s and those during course of hospitalization • T wave inversion is most common abnormality (68%) and best correlates to severity of PE Chest. 1997.

  10. Retrospective cohort study of pts with PE and age- and sex-matched controls (n=98) • All pts had CT PE done (no d-dimers available at that time in their institute) • All EKG reviewed by 2 cardiologists • ?discrete EKG findings for ED pts to rule-in vs. rule-out PE? J Emerg Med. 2004.

  11. EKG and PE • Kappa values were calculated for each EKG finding and varied from 0.14 to 1.0 • For normal T waves (k=0.17) and biphasic T waves (k=0.14) • Conclusion: no EKG findings specific or sensitive enough to help dx PE in ED.

  12. N=40 consecutive pts with PE and 87 consecutive pts with ACS • All pts had negative T waves >=1mm in 2+ contiguous precordial leads (V1-4) • Exclusion criteria: ST elevation>=2mm on 2+ precordial leads, Q wave MI, conditions precluding evaluation of ST segments, hx cardiopulmonary disease • Dx of PE made with pulm angio, V/Q, or spiral CT • Dx of ACS made with cardiac cath Am J Cardiol. 2007.

  13. Cont’d

  14. T wave inversion

  15. Conclusions • Combination of T inversion in V1 and III was more sensitive and specific for PE and rarely found in ACS (1%)

  16. "Excuse me. ... I know the game's almost over; but just for the record, I don't think my buzzer was working properly. by Gary Larson

  17. So based on that, which is PE?

  18. Anything unusual? Acute PE – S1Q3T3, T inversion V1-5 and III

  19. More cases… WPW – short PR, delta wave, wide QRS

  20. Next… CNS event – deeply “Wellenoid” T waves V2-5

  21. Final one… Digoxin toxicity – T inversion, prolonged PR, diffuse ST depression with distinct scooped appearance

  22. 3d after treatment with heparin…

  23. The time-line…

  24. Questions ?

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