EKG rounds

Rebecca Burton-MacLeod

R5, Emerg Med

Dec 13th, 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

• Any investigations?

• PS. Don’t forget…this is “EKG rounds”…

Presenting EKG

Ddx T wave inversion…

Am J Emerg Med. 2002.

Case cont’d

• Blwk:– TNT normal– D-dimer 3.27

• Investigations:– Echo: RV systolic dysfxn, mod-severe pulm

hypertension– CT confirmed PE

PE and EKG findings

• Classic findings:– Sinus tachycardia– S1Q3T3– Rt heart strain

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

• 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.

• 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.

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.

• 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.

Cont’d

T wave inversion

Conclusions

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

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by Gary Larsonby Gary Larson

So based on that, which is PE?

Anything unusual?

Acute PE – S1Q3T3, T inversion V1-5 and III

More cases…

WPW – short PR, delta wave, wide QRS

Next…

CNS event – deeply “Wellenoid” T waves V2-5

Final one…

Digoxin toxicity – T inversion, prolonged PR, diffuse ST depression with distinct scooped appearance

3d after treatment with heparin…

The time-line…

Questions ?