Rebecca Burton-MacLeod R5, Emerg Med Dec 13th, 2007 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: Investigations: TNT normal D-dimer 3.27 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.

All EKG reviewed by 2 cardiologists 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%)

"Excuse me. ... I know the game's almost over; but just for the record, I don't think my buzzer was working properly. by 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 ?