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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2818_Библиотеки_им_академика_М_И_Перельмана
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23 Digitalis Effect andToxicity
The rhythm strip of the same patient in Fig.23.7 shows digitalis toxicity. The
J point is depressed below the baseline. The S-T segment is depressed like a
reverse check sign but the T wave does not rise above the base line. Besides this
the P-R interval is 0.28s.
This patient was taking digitalis in appropriate dose which is reected in the
rst rhythm strip. However, he took double dose of digitalis that led to digitalis
toxicity. This patient was probably also taking loop diuretics due to heart failure.
Loop diuretics cause hypokalaemia and hypokalaemia precipitates digitalis toxicity. Hence, hypokalaemia should be ruled out in this patient and if detected
should be corrected. However, one must remember that the major electrolyte
disturbance in acute digoxin toxicity is hyperkalaemia.
Treatment with digoxin immune Fab is considered rst-line therapy for dysrhythmias including AV block and ventricular tachycardia caused by suspected
digoxin toxicity.
2. The rhythm strip (Fig.23.8) shows scooping S-T segment depression and the T
wave rises above the baseline. Most likely it is due to digitalis effect.
Chapter 24
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ECG inMiscellaneous Heart Diseases
Learning Objectives
After studying this chapter, the reader will learn about:
• Valvular heart disease
• Acute rheumatic carditis
• Pericardial disease
• Congenital heart disease
• Miscellaneous conditions
24.1 Valvular Heart Disease
Rheumatic heart disease is still common in many parts of the world. Rheumatic
carditis and resultant valvular heart disease can both lead to notable changes in an
ECG, aiding in their diagnosis and management. Rheumatic carditis, a consequence
of rheumatic fever, may present with prolonged P-R intervals, S-T, T wave abnormalities and atrial brillation. Valvular heart disease, such as aortic stenosis or
regurgitation, mitral stenosis or regurgitation and tricuspid regurgitation can exhibit
distinct ECG ndings. Valvular diseases can cause both structural and functional
changes in the heart. These include left ventricular hypertrophy, left or right atrial
enlargement, repolarization abnormalities and various P wave abnormalities.
Accurate interpretation of ECG changes in rheumatic carditis and valvular heart
disease plays a pivotal role in identifying these conditions, guiding treatment decisions and monitoring patient progress.
Ltd. 2024
T. K. Koley, Rapid Review of ECG,
https://doi.org/10.1007/978-981-99-9116-7_24
311© The Author(s), under exclusive license to Springer Nature Singapore Pte
312
25 mm/s. 10 mm = 1 mV
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24 ECG inMiscellaneous Heart Diseases
24.1.1 Mitral Stenosis
Mitral stenosis is usually of rheumatic origin. There is left atrial and right ventricular hypertrophy (Figs.24.1 and 24.2). In long standing cases, there is right atrial
enlargement. Pulmonary hypertension is commonly observed in these patients.
They often suffer from atrial brillation. The various ECG manifestations of mitral
stenosis are:
• P mitrale in lead II and biphasic P wave in lead V1
• P pulmonale is present in mitral stenosis with pulmonary artery hypertension
• Features of RVH (R:S ratio>1in lead V1 with S-T segment, T wave change)
• Right axis deviation
• Presence of atrial brillation (absence of P wave with varying R-R interval)
24.1.2 Mitral Regurgitation
Mitral regurgitation is due to several causes like rheumatic heart disease, dilated
cardiomyopathy, mitral valve prolapse, etc. There is left ventricular and left atrial
hypertrophy. Pulmonary hypertension is usually absent. Atrial brillation may be
seen. The ECG manifestations are:
V1
Fig. 24.1 Mitral stenosis
II
V2
III
V3
aVR
V4
aVLIaVL
V5
aVF
V6
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24.1 Valvular Heart Disease
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313
I
II
III
II
Fig. 24.2 Mitral stenosis. This ECG is recorded from a 17-year-old boy suffering from pure mitral
stenosis. Note the tall R waves in lead V1 with small S waves and S-T segment, T wave changes
suggestive of gross RVH.Note the biphasic P wave in leads V1 and V2 and tall P wave in lead
II.Also note the widening of P wave in lead I
aVR
aVL
aVF
V2
V1
V3
V4
V5
V6
• Left atrial enlargement (deep and prominent negative component of biphasic P
wave in lead V1)
• Left ventricular hypertrophy due to diastolic overload (S in lead V1 plus R in
lead V5 or V6 is >35mm, with S-T segment, T wave change in lead V5 or V6)
• Normal QRS axis
• Atrial brillation (absence of P wave with varying R-R interval)
24.1.3 Aortic Stenosis
In aortic stenosis, there is concentric hypertrophy of left ventricle. There is systolic
overload of the left ventricle. The ECG features are:
• Left ventricular hypertrophy (S in lead V1 plus R in lead V5 or V6 is >35mm,
with S-T segment, T wave change in lead V5 or V6)
• Normal QRS axis
• Incomplete left bundle branch block (rSr’ complex in lead V5 or V6 with QRS
duration <0.12s)
• Left atrial enlargement
• Inversion of U wave
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24 ECG inMiscellaneous Heart Diseases
24.1.4 Aortic Regurgitation
Aortic regurgitation is often of rheumatic origin. There is volume overload of the
left ventricle. There is gross hypertrophy of the left ventricle. The left atrium is also
enlarged. The ECG manifestations are:
• Left ventricular hypertrophy (diastolic overload pattern)
• Left atrial enlargement
• Usually normal QRS axis, sometimes left anterior hemiblock may be seen
• Sometimes inversion of U wave is seen
24.1.5 Acute Rheumatic Carditis
Acute rheumatic carditis occurs during acute rheumatic fever. Myocardium, pericardium and the endocardium are involved. The ECG manifestations of acute rheumatic carditis are:
• Prolonged P-R interval
• Sinus tachycardia
• Features of acute pericarditis
• Features of acute myocarditis
(a) Depression or elevation of S-T segment
(b) Notching or slurring of QRS complex
(c) Non-specic T wave changes
(d) Prolonged Q-Tc interval
24.2 Pericardial Diseases
Pericardial diseases can give rise to characteristic ECG changes that aid in their
diagnosis and management. Pericarditis and pericardial effusion are common clinical condition where ECG plays a major role in making a diagnosis.
24.2.1 Pericarditis
Pericarditis may be of viral or bacterial origin. Tuberculous pericarditis is also very
common. It is often associated with pericardial effusion. Uraemia is also an important
cause of pericarditis. Acute pericarditis is diagnosed by the following ECG features:
• Sinus tachycardia
• S-T segment elevation with upward concavity in leads oriented towards the
affected surface (Fig.24.3)
• T wave inversion (this occurs after S-T segment becomes isoelectric)
• Sometimes depression of P-R segment is seen
V1 V2
V3
V4
V5
V6
24.3 Congenital Heart Disease
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I
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Fig. 24.3 Acute pericarditis
II
III
aVR
aVL
aVF
24.2.2 Pericardial Effusion
There are several causes of pericardial effusion. Tuberculosis, uraemia, viral pericarditis are some of the common causes. There is collection of uid in the pericardial sac that compresses the heart often leading to cardiac tamponade. The ECG
features of pericardial effusion are:
• Low voltage complex, i.e. less than 5mm amplitude in standard leads and less
than 10mm amplitude in chest leads (Figs.24.4 and 24.5)
• T wave inversion in most of the leads except aVR
• Electrical alternans (alternating low and normal voltage QRS complexes)
24.3 Congenital Heart Disease
Congenital heart disease (CHD) encompasses a broad range of structural abnormalities in the heart present at birth. ECG changes can provide valuable insights
into the presence and severity of CHD.ASD, VSD and Fallot’s tetralogy are some
of the common CHDs that we come across in day-to-day clinical practice. The
structural deformities and the functional changes due to CHDs produce numerous
changes in the ECG including abnormalities in P wave, QRS complex and QRS
axis. These ECG ndings, combined with clinical evaluation, aid in diagnosing and
managing individuals with CHD, facilitating timely intervention when necessary.
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V3 V4 V5 V6
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III III aVR aVL aVF
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V1 V2
24 ECG inMiscellaneous Heart Diseases
Fig. 24.4 Pericardial effusion
I
II
III
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aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
Fig. 24.5 Pericardial effusion. This ECG is recorded from a 45-year-old gentleman suffering from
tubercular pleural effusion. Note the low voltage complexes with sinus tachycardia
24.3.1 Atrial Septal Defect
Atrial septal defect (ASD) is of two types: ostium secundum type and ostium primum type. Ostium secundum defect is not associated with any malformation of the
AV canal. In this defect, there is volume overload of right atrium and right ventricle
(Figs.24.6 and 24.7). The ECG features of ostium secundum type of ASD are the
following:
V1 V2 V3 V4 V5 V6
V1 V2
V3
V4
V5 V6
24.3 Congenital Heart Disease
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• rsR’ complex in lead V1 with biphasic P wave
• Right axis deviation
• Right atrial enlargement
• Decrease in amplitude of R wave in leads V5 and V6
• Atrial brillation and atrial utter may be observed
• Clockwise electric rotation: The transition zone is shifted to lead V5 or V6
Ostium primum defect is often associated malformation of atrioventricular canal.
The ECG features of ostium primum type of ASD are:
• rsR’ complex in lead V1
• Left axis deviation
I III
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II
Fig. 24.6 Atrial septal defect
IIII
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II
aVR
aVR
aVL aVF
aVL aVF
Fig. 24.7 Atrial septal defect
318
V1 V2
V3
V4
V5 V6
La
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24 ECG inMiscellaneous Heart Diseases
• First degree AV block
• Atrial arrhythmias
24.3.2 Ventricular Septal Defect
The ventricular septum is made up of a membranous part and a muscular part. Most
of the defects lie in the membranous part of the interventricular septum. The muscular part is rarely affected. There is left to right shunt. There is volume overloading
of the left atrium and the left ventricle. Due to gradual increase in the pulmonary
resistance, there is increase in right ventricular pressure, i.e. systolic overload. In
later stage, there may be reversal of shunt resulting in Eisenmenger complex. The
ECG features of VSD are the following:
• Features of left ventricular hypertrophy or combined left and right ventricular
hypertrophy
• Large amplitude equiphasic QRS deections in leads V2, V3 and V4 (Fig.24.8)
• Prominent q waves in leads II, III and aVF
• QRS axis is normal but with development of pulmonary hypertension there may
be right axis deviation
I III
Fig. 24.8 Ventricular septal defect
II
aVR
aV
VF
V1 V2
V3
V4
V5 V6
24.3 Congenital Heart Disease
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IIII
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Fig. 24.9 Fallot’s tetralogy
II
aVR
aVL aVF
24.3.3 Fallot’s Tetralogy
Fallot’s tetralogy is the commonest congenital cyanotic heart disease in the adults.
The four defects in the heart are a) infundibular pulmonary stenosis, b) dextroposition of aorta, c) ventricular septal defect, d) right ventricular hypertrophy. The ECG
features of Fallot’s tetralogy are:
• Right ventricular hypertrophy due to systolic overload (Fig.24.9)
• Tall and peaked P waves in lead II due to right atrial enlargement
24.3.4 Pentalogy ofFallot
In this rare condition, there are all the features of tetralogy along with ostium secundum ASD.There is volume overloading of left atrium and left ventricle. Thus, there
is enlargement of all the cardiac chambers. The ECG features consist of right atrial
enlargement with right ventricular hypertrophy (systolic overload) and mild left
ventricular hypertrophy (diastolic overload).
24.3.5 Trilogy ofFallot
Trilogy of Fallot is pulmonary stenosis (valvular) with any of the following types of
interatrial septal defect: (a) patent foramen ovale, (b) ostium secundum ASD, (c)
ostium primum ASD.The ECG features are:
• Right atrial hypertrophy
• Right ventricular hypertrophy due to systolic overload
• Possible left atrial and left ventricular hypertrophy
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