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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

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ecg case studies

ECG Case Studies

Moosa Kalla

case 1
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 findings
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

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
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
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
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 findings11

Rate: 75

Rhythm: sinus

PRI: normal

Axis: normal

QRS:RSR V1 V2, Incomplete RBBB

ST elevation V1 V2, downsloping

brugada syndrome
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 Cardio-defibrilator(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
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 findings16
ECG Findings


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
LAB findings

Trop t negative

WCC 12.5

ESR 50

Urgent angiography showed healthy coronary arteries


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


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

case 4
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


Rate: 80

Rythym: sinus

PR: normal


ST seg: global discordance

: concordance V4 1 mm

sgarbossa criteria
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


ST segment deviations only ECG findings useful in diagnosisng acute myocardal infarction in the presence of LBBB

criteria selected
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
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
hospital course
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
echo findings at 24 hours
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 findings39
ECG Findings
  • Rate: 100
  • Rythym: sinus
  • PRI: normal
  • Axis: left
  • QRS: narrow
  • ST seg: STE V-V5
  • : biphasic V3-V5
  • : inverted V6
tokatsubo cardiomyopathy
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


Typically triggered by emotional, physical or medical stressors

Commonly present with SOB


ECG changes of ischaemia

postulated mechanisms
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
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
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

ecg findings47
ECG findings
  • Rate: 66
  • Rythym: ventricular paced
  • Axis: left
  • :Q waves V1-V6
  • ST seg: discordant all leads except V2
  • Rate: 66
  • Rythym: sinus
  • Axis: normal
  • PRI normal
  • ST seg: STE II III aVF
  • : reciprocal changes aVL and
  • V2

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


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 . 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

  • Karen marzlin;Clinical insights from unusual case studies in cardiovascular care:NIT 2008;
  • 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
  • J Knott;Diagnosis of acute myocardial infarction with ventricular paced rythym;Emergency Medicine 2003 15 (100-103)
  • HC CHEW,SH LIM; ECG case.ST Elevation:Is this an infarct?; Singapore med Journal; 2005 46 (11): 656
  • A De Meester et al; Symptomatic pericarditis after influenza vaccine . CHESTT / 117/6 June 200 p 1803-1805
  • A Mattu,W Braddy; ECG’s for the Emergency Physician, BMJ 2003