ECG rounds: The ECG in (pre)syncope Jay Green PGY-4, Emergency Medicine Resident August 13, 2009

Objectives Appreciate some significant ECG changes in the context of the patient with (pre)syncope Briefly review some potentially worrisome diagnoses that can present with (pre)syncope and an abnormal ECG

Case 1 17y M Lightheaded, diaphoretic, nausea x ?minutes Felt fine afterwards Occasional similar episodes, none this bad Occasional palpitations No CP/SOB Exam unremarkable

Case 1 - ECG WPW

WPW Issue? Preexcitation through accessory tract Risk of tachydysrhythmia/death (0.1% risk of SCD) Tx: ablation of pathway, medical tx (IC (propafenone), III (amio)) ECG Short PR (<0.12sec) Prolonged QRS > 0.10 sec Delta wave +/-T wave changes, large inferior Q’s

Case 2 31y F PMH nil Syncope at work Feels fine, wants to return to work Exam unremarkable

Cae 2 - ECG Brugada – 131 (SR with sinus arrhythmia, STE in R precordial leads)

Brugada Issue? Autosomal dominant Na-channel disorder, first described in 1992 Predisposed to VT (poly>mono), sudden death Tx: ICD Mortality 10%/yr without ICD ECG Incomplete RBBB or RBBB in V1-3 & STE STE convex-up > concave-up Type I (coved with TWI) Type II/III (Saddle)

Case 3 25y M athlete Lightheaded, palpitations during basketball game Feels well now, “Put me in coach!”

Case 3 - ECG HOCM – 158 (SR, large amplitude QRS, abN narrow Q’s in lat leads) LVH - V1/2S + V5/6R (tallest) > 35mm, or aVL-R > 11mm (only apply >40y)- get repol abN (abN T/ST) bc large muscle doesn't repol as N

Hypertrophic Cardiomyopathy Issue? Dynamic outflow tract obstruction Predisposed to sudden cardiac death (initial sign in many) Annual mortality of 6% in young athletes (1% in elderly) Tx: BBl, +/-CCB, amio (for afib), septal myomectomy ECG (Any or all of) Large amplitude QRS like LVH Deep/narrow Q in inf and/or lateral leads Tall R in V1-2

Practice time WPW Brugada HOCM A few others…

31y M syncope Brugada (coved) – 111 (SR, LVH (V2S + V5R > 35mm), incRBBB with STE in V1-2)

51y M syncope WPW (short PR, QRS ?wide, delta, large Q’s in inf leads)

51y F CP x 3h then syncope 3*HB – 160 (ST, AV dissociation, jct rhythm, incRBBB, atrial rate 110, vent rate 40, STD V2-5 (?ischemia))

29y M severe lightheadedness & palpitations x 30min HOCM – 186 (ectopic atrial rhythm (invP in III), large QRS voltage (?LVH), abN narrow Q’s in 1/aVL)

55y F occasional syncope, recent palpitations WPW – 81 (short PR <0.12sec, QRS >0.10sec, delta, large inf Q’s) -

57y M schizophrenia, syncope >QTc 147 – overdose of antipsychotic meds (sinus arrhythmia, >QTc, 0.581sec) -risk of developing TdP

30y F ongoing palpitations, lightheadedness WPW + AF – 136 (irregular WCT, QRS marked morphology variation)

82y M syncope, bp 70/35 now 3*HB 151 (ST with AV dissociation, atrial rate 100, vent rate 25, TWI precordial leads, inf T flattening (nonSP)) ((-no P waves conducted = 3* HB, occasional P wave conducted = AV dissociation))

30y M presyncope HOCM – 122 (SR, large amplitude QRS (?LVH), abN narrow Q’s in I, aVL, tall R V1/2)

54y healthy F, found dead by family, ECG 1wk ago Brugada (coved) – 182 (SR, incRBBB with STE in V1-2)

54y M homeless, long hx of syncopal episodes WPW – 102 (SR, LVH, intermittent delta wave (complex 2, 5, 8, 9)) -amplitude/morphology of QRS changes within each lead (abN conduction)

85F syncope, still lightheaded Mobitz II 42 (LBBB) -Mobitz II is usually associated with BBB

Questions?

36yF presyncope WPW - 66 (wide QRS, delta, short PR, tall R in V1, LAD)

71y F CRF, syncope >QT 44 – hCa? (septal Q’s (old), ant TWI (old), QTc 0.565sec)

44y alcoholic, vomiting, syncope during ECG TdP 89 (hK, hMg)