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

2. 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

3. 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

4. Case 1 - ECG
WPW

5. 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

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

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

8. 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)

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

11. 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

12. 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

13. Practice time
WPW
Brugada
HOCM
A few others…

14. 31y M syncope
Brugada (coved) – 111 (SR, LVH (V2S + V5R > 35mm), incRBBB with STE in V1-2)

15. 51y M syncope
WPW (short PR, QRS ?wide, delta, large Q’s in inf leads)

16. 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))

17. 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)

18. 55y F occasional syncope, recent palpitations
WPW – 81 (short PR <0.12sec, QRS >0.10sec, delta, large inf Q’s) -

19. 57y M schizophrenia, syncope
>QTc 147 – overdose of antipsychotic meds (sinus arrhythmia, >QTc, 0.581sec)
-risk of developing TdP

20. 30y F ongoing palpitations, lightheadedness
WPW + AF – 136 (irregular WCT, QRS marked morphology variation)

21. 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))

22. 30y M presyncope
HOCM – 122 (SR, large amplitude QRS (?LVH), abN narrow Q’s in I, aVL, tall R V1/2)

23. 54y healthy F, found dead by family, ECG 1wk ago
Brugada (coved) – 182 (SR, incRBBB with STE in V1-2)

24. 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)

25. 85F syncope, still lightheaded
Mobitz II 42 (LBBB)
-Mobitz II is usually associated with BBB

26. Questions?

28. 36yF presyncope
WPW (wide QRS, delta, short PR, tall R in V1, LAD)

29. 71y F CRF, syncope
>QT 44 – hCa? (septal Q’s (old), ant TWI (old), QTc 0.565sec)

30. 44y alcoholic, vomiting, syncope during ECG
TdP 89 (hK, hMg)