ECG Case Studies Moosa Kalla Case 1 • • • • • • • 52 yr old man No Hx of IHD Known HPT on Rx Presents with acute onset chest Initial ECG.
Download ReportTranscript ECG Case Studies Moosa Kalla Case 1 • • • • • • • 52 yr old man No Hx of IHD Known HPT on Rx Presents with acute onset chest Initial ECG.
ECG Case Studies Moosa Kalla 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 ECG 24 Hrs post admission 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 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 • • • • • • 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 • 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 • • • • • 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 • • • • • • • • • 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 • • • • 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 . • 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 • • • • 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 • • • • • • 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 • 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 • • • • 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 • • • • • • • • 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 • • • • • • 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 • • • • • • • • Rate: 66 Rythym: sinus Axis: normal PRI normal QRS: LBBB ST seg: STE II III aVF : reciprocal changes aVL and V2 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 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 • 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