1. Rebecca Burton-MacLeod R5, Emerg Med Dec 13th, 2007
EKG rounds
Rebecca Burton-MacLeod
R5, Emerg Med
Dec 13th, 2007

2. 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

3. Case cont’d
Any investigations?
PS. Don’t forget…this is “EKG rounds”…

4. Presenting EKG

5. Ddx T wave inversion…
Am J Emerg Med

6. Case cont’d Blwk: Investigations: TNT normal D-dimer 3.27
Echo: RV systolic dysfxn, mod-severe pulm hypertension
CT confirmed PE

7. PE and EKG findings Classic findings: Sinus tachycardia S1Q3T3
Rt heart strain

8. 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

9. 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

10. 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

12. 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.

13. 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

14. Cont’d

15. T wave inversion

16. Conclusions
Combination of T inversion in V1 and III was more sensitive and specific for PE and rarely found in ACS (1%)

17. "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

18. So based on that, which is PE?

19. Anything unusual?
Acute PE – S1Q3T3, T inversion V1-5 and III

20. More cases…
WPW – short PR, delta wave, wide QRS

21. Next…
CNS event – deeply “Wellenoid” T waves V2-5

22. Final one…
Digoxin toxicity – T inversion, prolonged PR, diffuse ST depression with distinct scooped appearance

23. 3d after treatment with heparin…

24. The time-line…

25. Questions ?