Interesting Case / ECG rounds

Nov 5, 2009

Garth Smith CCFP-EM

A case•26 yo F, H.W., previously healthy

• chest pain

•5 day hx, squeezing, deep within L chest, occ rad to L shoulder. prior to 5d ago, feeling well. Had flu shot. today symptoms assoc with mild SOB, mild HA, and feeling like she was going to faint. episodes last 30-120 sec. occur 2-3 x/day. non excertional. no alleviating/aggravating factors

HPI• no change with position. no prodromal URTI

• no pleuritic component, no DVT risks, no BCPs/hormones

• no radiation to back, not maximal at onset, not tearing

• no nausea/emesis/diaphoresis/indigestion

• no dysphagia

• no trauma to chest wall, no physical activity out of normal routine

• no history of arthritis, no pleurisy, no inflammatory conditions

• no history of recent stress or “broken heart”

• no history of migraines nor Raynaud’s

• no cocaine/stimulants

HPI•history of GERD with pregnancy. Feels very

different

•history of panic attacks. Those too are different

•1 year hx of senstation of occ “skipped heart beat” assoc with presyncope. 1 episode/month. Feels different. FP has organized O/P echo.

•ROS: no heat intolerance, no bowel changes, no skin/hair changes, no urine changes, etc, etc...

• PMHx: G2P2A0, last delivery -11/12

• Med: none. no OTCs

• All: ASA (seizure as toddler)

• SHx: exsmoker (8pk yr), mod ETOH (denies binge), works in calgary hospital as unit clerk, no drugs (experimented with amphetamines several years ago), married, 2 children, happy, normal stressors of young family life

• FHx: father angina, CABG @56, no sudden death, no known arrhythmias

Summary

•young healthy woman with atypical chest pain. No obvious etiology. Minimal CAD risks.

•Still having some chest pain in ED

DDx?

DDx?

•MSK

•arrhythmia (SVT, afib)

•cocaine / meth

•ETOH or Marijuana (holiday heart)

•panic attack / anxiety

•coronary artery vasospasm ACS ?

Physical Exam

•Vitals: 36.2, 98, 16, 122/82, 99%RA

•Physical exam unremarkable

•normal heart sounds, chest clear

•no chest wall pain, no rash, no calf pain/swelling

Labs•Hgb 147, WBC 6.9, Plat 221

• INR 1.0, PTT 32.8

•Na 140, K 3.5, Cl 105, CO2 26

•Cr 53

•Glu 4.9

• Liver Enzymes normal

•Trop <0.03•D-dimer <0.10

Investigations

•CXR

Investigations

•ECG

with pain

T

Normal T wave• represents the ventricular repolarization

(phase 3 of cardiac action potential)

• usually smooth and round, slight asymetry

• amplitude usually <0.5mV in limb leads and <1.0mV in precoridal leads

• positive in I, II, V3-V6

• negative in aVR

• variable in III, aVL, aVF, and V1-V2

DDx Inverted T wave• ACS (ischemia, NSTEMI,

STEMI)

• Wellen’s syndrome

• myocardial contusion

• cardiomyopathy

• post infarction, post reperfusion

• BBB

• Pericarditis / myocarditis

• PE

• LVH (with “strain”)

• Digitalis

• apical hypertrophy (Yamaguchi syndrome)

• lead misplacement

•CNS injury (NCSE, SAH, SDH, EDH, CVA)

•ventricular paced rhythm

•post supraventricular tachycardia

•intra abdominal disorders

•Metabolic / toxic syndromes

•Preexcitation syndrome

•Juvenile T wave pattern

•anxiety / hyperventilation

•postural / post prandial

•normal variant (athlete’s heart, pregnancy)

Chan. ECG in Emergency Medicine and Acute Care. 1st ed. Mosby 2005

Pillarisetti . Giant Inverted T waves in the emergency department: case report and review of differential diagnoses . J of

Electrocardiology. article in press. 2009

Scary Not ScaryACS (ischemia, NSTEMI, STEMI)

Wellen’s syndrome

myocardial contusion

LVH (with “strain”)

BBB

cardiomyopathy

post infarction

ventricular paced rhythm

CNS injury

PE

intra abdominal disorders

Metabolic / toxic syndromes

post supraventricular tachycardia

post reperfusion

Digitalis

apical hypertrophy (Yamaguchi syndrome)

Juvenile T wave pattern

anxiety hyperventilation

postural / post prandial

normal variant

lead misplacement

Pericarditis / myocarditis

preexcitation syndrome

Catanzaro . Electrocardiographic T-wave changes underlying acutecardiac and cerebral events. American Journal of Emergency Medicine.2008; 26, 716–720

ACS•T-wave inversions produced

by myocardial infarction (MI) are classically narrow and symmetric

Hayden. Electrocardiographic T-Wave Inversion: Differential Diagnosis in the Chest Pain Patient. American Journal of

Emergency Medicine. 2002; 20:3, 252-262

Wellen’s•non-infarction ACS

•symmetric deeply inverted, usually V2 and V3

•frequently occur in pain free state

Chan. ECG in Emergency Medicine and Acute Care. 1st ed. Mosby 2005

CNS injury• symmetric, deeply inverted

•range from small to prominent

•etiology is elusive

•Several mechanisms have been suggested including microvascular spasm and increased levels of circulating catecholamines

Chan. ECG in Emergency Medicine and Acute Care. 1st ed. Mosby 2005

PE•T wave inversions of varying magnitude may

be seen in precordial leads usually V1 to V4

• size of T waves related to the severity of PE

• typically symmetric

• remember S1Q3T3 pattern (less than 25% have this)

• inverted T waves eventually normalize post thrombolysis or proteolysis of the clot

Chan. ECG in Emergency Medicine and Acute Care. 1st ed. Mosby 2005

LVH

•strain pattern

•repolarization abnormality

•ST segment depression with asymmetric biphasic or inverted T waves with prominent R wave

Chan. ECG in Emergency Medicine and Acute Care. 1st ed. Mosby 2005

BBB

•inverted T waves in leads with predominantly positive QRS complexes

•widely splayed and asymmetric

•amplitude ranges from minimal to significant

Chan. ECG in Emergency Medicine and Acute Care. 1st ed. Mosby 2005

Digitalis

•T wave usually inverted and a component of the depressed ST segment

•“scooping ST segment”

Chan. ECG in Emergency Medicine and Acute Care. 1st ed. Mosby 2005

Myocarditis / Pericarditis

•T wave inversions are frequently small in size and symmetric in morphology

•late stage finding usually 3 weeks into disease, consequently, not seen often

Chan. ECG in Emergency Medicine and Acute Care. 1st ed. Mosby 2005

Juvenile •appear in the precordial

leads V1, V2, V3

•normal in the child and young adolescent

• inversions usually small in amplitude and symmetric

•should evolve into the normal upright pattern by mid teens

Chan. ECG in Emergency Medicine and Acute Care. 1st ed. Mosby 2005

with pain

Scary Not ScaryACS (ischemia, NSTEMI, STEMI)

Wellen’s syndrome

myocardial contusion

cardiomyopathy

LVH (with “strain”)

BBB

post infarction

ventricular paced rhythm

CNS injury

PE

intra abdominal disorders

Metabolic / toxic syndromes

post supraventricular tachycardia

post reperfusion

Digitalis

apical hypertrophy (Yamaguchi syndrome)

Juvenile T wave pattern

anxiety / hyperventilation

postural / post prandial

normal variant

lead misplacement

Pericarditis / myocarditis

preexcitation syndrome

What ja gonna do?

+3 hrs, no pain

+3.5 hrs, with pain

dynamic ECG changes

DDx?

• coronary artery vasospasm

• ischemia? ACS?

• cardiomyopathy

• arrhythmia (SVT, afib, other)

• cocaine / meth

• ETOH or Marijuana (holiday heart)

• panic attack / anxiety

What ja gonna do?

Results• CCU consulted

• patient kept in ED O/N, plan to do EST in am and d/c home

• patient failed EST because of chest pain (but no dynamic ECG changes) which resolved immediately with cessation of test

• started ticlopidine (anti platelet alternative to ASA)

• admitted to 81/82

• repeat trops all negative

• ECHO normal

• Stress Myocardial Perfusion Imaging normal

• discharged home day 3 with reassurance of no CAD

• Dx: chest pain NYD

• f/u with FP, consider Holter for SVT, afib, or other arrhythmia

Other?

•alternative approaches?

•if the repeat ECG still had inverted T waves with no pain, would you still consult CCU or send home?

•would you have done any other investigations or management in ED?

Chest pain with dynamic ECG

changes• small study, 72 patients

• dynamic ECG changes (ST↕ or T↓ with pain then normalization when pain free)

• two groups: typical(39) vs atypical (33)cp

• all underwent angio

• only 2 patients (6%) of atypical group had CAD

• Conclusions: Patients with atypical chest pain and dynamic ECG changes have very low likelihood of having CAD. Young females may have dynamic ECG changes without having CAD

Bhardwaj. Chest Pain, Dynamic ECG changes and Coronary Artery Disease. JAPI. 2007; 55: 556-559

Conclusions• Risk stratification of chest pain patients is

challenging

• ECG is a diagnostic tool to help in this situation. High risk findings include: signs of ischemia/infarction, strain, LVH, LBBB, paced rhythm

• T wave inversion is nonspecific finding and must be used in correlation with the rest of the ECG and the clinical presentation

• think about the DDx and collect history/data to rule out life threatening possibilities

Brush JE Jr, Brand DA, Acampora D, Chalmer B, Wackers FJ. Use of initial electrocardiogramto predict in-hospital complication of myocardial infarction. N

Eng J Med. 1985;312:1137-4115

Questions?