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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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330
25 mm/s. 10 mm = 1 mV
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24 ECG inMiscellaneous Heart Diseases
I
V1
II
V2
Fig. 24.20 Interpret the ECG
25 mm/s. 10 mm = 1 mV
III III
V1 V2
III
V3
V3
aVL
V4
aVR aVL aVF
V4
V5
V5
aVFaVR
V6
V6
Fig. 24.21 Interpret the ECG
Lead II 25 mm/s. 10 mm = 1 mV
Fig. 24.22 Analyse the rhythm strip
24.4 Miscellaneous Conditions
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Answers
1. True 2. True 3. True 4. False 5. True 6. b 7. b 8. a 9. a 10. a
Case Studies
1. The ECG (Fig.24.19) shows S-T segment elevation with concavity upwards in
leads I, II, aVL and V2–V6. The T waves are not inverted and there are no Q
waves. In light of the clinical features, the ECG is diagnostic of acute pericarditis. Most likely pericarditis is of viral origin.
Echocardiography should be performed to rule out pericardial effusion. CRP
is usually high in acute pericarditis. Pericarditis is treated empirically with
NSAIDs. Colchicine may be used to treat recurrent pericarditis or that does not
respond to conventional treatment.
2. The ECG (Fig.24.20) shows P pulmonale, right bundle branch block, deep S
waves in lead V5 and lead V6 and right axis deviation. Correlating with the clinical features, it is a case of ostium secundum ASD.If there was left axis deviation, a diagnosis of ostium primum ASD would be made.
Echocardiography is the gold standard for diagnosis of ASD.Defects that are
greater than 1cm will most likely require medical/surgical intervention to close
the defect. If an ASD requires closure, options include percutaneous and surgical
intervention. Percutaneous transcatheter closure may be considered in this
patient.
3. The ECG (Fig.24.21) shows short P-R interval (< 0.12s), delta wave and wide
QRS complex (> 0.12s). Delta waves are clearly visible in leads I, aVL, V1–V6.
This ECG is diagnostic of WPW syndrome.
In general, asymptomatic, young, healthy patients without comorbid conditions who have the WPW pattern on ECG and without a history of suspected
tachyarrhythmia will require cardiology follow-up. However, patients who have
suffered tachyarrhythmias should be referred for close cardiology follow-up for
risk stratication testing and/or electrophysiologic study with accessory pathway mapping and possible ablation. Accessory tract ablation is commonly done
by radiofrequency current ablation, but cryoablation can also be utilized.
4. The ECG (Fig.24.22) shows electrical alternans. One large QRS complex is
alternating with a QRS complex of smaller amplitude. Electrical alternans is
seen in pericardial effusion.
Most likely this patient is suffering from pulmonary tuberculosis with pericardial effusion. Echocardiography will conrm the presence of uid in the pericardial sac. Small effusions usually do not require any treatment. The patient
should receive anti-tubercular treatment and should be asked for follow-up on a
regular basis.
Large effusions may need a diagnostic and therapeutic pericardiocentesis to
evaluate the aetiology and drained to provide symptomatic relief if the patient
has associated symptoms such as dyspnoea, chest discomfort, pulmonary
oedema or lower extremity oedema.
Chapter 25
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ECG inMiscellaneous Clinical Conditions
Learning Objectives
After studying this chapter, the reader will learn about:
• Myxoedema
• Hyperthyroidism
• Pulmonary embolism
• COPD
• Hypothermia
• Neuromuscular disease
• SI, SII, SIII syndrome
In this chapter, ECG changes of some common diseases will be discussed. It is very
important to understand the changes, as ECG is often the rst investigation for these
diseases that help us in making a diagnosis and start appropriate treatment.
25.1 Myxoedema
In myxoedema, body metabolism is decreased. There may be pericardial effusion.
The ECG features of myxoedema are the following:
• Low voltage complex (Fig.25.1)
• Sinus bradycardia
• Shallow or inverted T waves
• Prolonged P-R interval
Ltd. 2024
T. K. Koley, Rapid Review of ECG,
https://doi.org/10.1007/978-981-99-9116-7_25
333© The Author(s), under exclusive license to Springer Nature Singapore Pte
334
V1 V2
V3
V4
V5 V6
La
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25 ECG inMiscellaneous Clinical Conditions
I III
25 mm/s. 10 mm = 1 mV
Fig. 25.1 Myxoedema
II
aVR
aV
VF
25.2 Hyperthyroidism
Hyperthyroidism is due to effect of excess circulating thyroid hormones. The body
metabolism is increased and hence there is tachycardia, which is a cardinal feature
of hyperthyroidism. The ECG features are:
• Sinus tachycardia
• S-T segment, T wave change in left ventricular chest leads
• Atrial and ventricular extrasystoles
• Atrial brillation
25.3 Pulmonary Embolism
Acute pulmonary embolism is characterized by sudden onset of chest pain and dyspnoea. There is sudden right ventricular strain. Often these patients suffer from various types of cardiac arrhythmias. Sinus tachycardia is the commonest ECG nding.
It is diagnosed electrocardiographically by the following criteria:
• SI, QIII, TIII pattern, i.e. prominent S wave in lead I, Q wave in lead III and T
wave inversion in lead III (Figs.25.2 and 25.3)
• Right axis deviation
• S-T segment depression in leads I and II
• Tall peaked P waves may appear in lead II
• T inversion in leads V1–V3 due to right ventricular ischaemia
• Low voltage complexes
• RBBB
• Atrial arrhythmias
La
25 mm/s. 10 mm = 1 mV
V1 V2
V3
V4
V5 V6
La
25.4 Chronic Obstructive Pulmonary Disease
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335
III III
V1
Fig. 25.2 Pulmonary embolism. There is sinus tachycardia with T wave inversion in leads V1 and
V2. Note the SI, QIII and TIII pattern
I III
25 mm/s. 10 mm = 1 mV
Fig. 25.3 Acute pulmonary embolism. Note the SI, QIII and TIII pattern
V2
II
V3
aVR
V4
aVR
aV
V5
aV
VF
V6
VF
25.4 Chronic Obstructive Pulmonary Disease
Chronic obstructive pulmonary disease (COPD) is a very common disease. Patients
often present with acute exacerbation. In long standing cases, there is right ventricular hypertrophy with pulmonary hypertension. There is right atrial enlargement as
well. These patients often suffer from rhythm disturbances and conduction
disturbances.
The ECG manifestations are:
• P-pulmonale (height of P wave > 2.5mm), best seen in leads II, III and aVF
(Figs.25.4 and 25.5)
• Clockwise rotation
• Right axis deviation
• Right ventricular hypertrophy (R:S ratio>1in lead V1)
• Decreased amplitude of QRS complexes
• Incomplete or complete right bundle branch block (rSR’ complex in lead V1
with S-T segment, T wave change and QRS duration > 0.12s)
336
V1 V2
V3
V4
V5
V6
Lead II 25 mm/s. 10 mm = 1 mV
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25 ECG inMiscellaneous Clinical Conditions
I III
25 mm/s. 10 mm = 1 mV
Fig. 25.4 Chronic obstructive pulmonary disease
Fig. 25.5 Note the tall and peaked P wave of COPD (p pulmonale)
II
aVR aVL
25.5 Hypothermia
aVF
Hypothermia is mainly due to exposure to cold air or water for a long time. Osborne
wave or J wave is the characteristic nding of hypothermia. Ventricular brillation
may be seen when the core temperature falls below 28°C.The ECG features of
hypothermia are the following:
• Presence of J waves (Fig.25.6)
• Prolongation of P-R, QRS and Q-T intervals
• Atrial brillation
• Sinus bradycardia
• AV junctional rhythm
• Ventricular brillation may occur
V5 V6
La
V1 V2
V3
V4
25.7 SI, SII, SIII Syndrome
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IIII
25 mm/s. 10 mm = 1 mV
Fig. 25.6 Hypothermia. The J waves are shown with arrow
II
aVR
aV
VF
25.6 Neuromuscular Diseases
ECG changes are often seen in neuromuscular diseases. These diseases are
Friedreich’s ataxia, progressive muscular dystrophy, etc. The ECG changes are the
following:
• First-degree heart block
• Various types of arrhythmias
• Non-specic S-T segment, T wave changes
25.7 SI, SII, SIII Syndrome
SI, SII, SIII syndrome means there are S waves in all the three standard leads. There
are several causes of this syndrome. It can be seen in normal healthy adults who do
not have any heart disease. It is often considered a normal variant. It may be the
persistence of physiological dominance of the right ventricular outow tract, which
is present during infancy. It can also be seen in those congenital heart diseases,
which have right ventricular dominance like Fallot’s tetralogy, pulmonary atresia,
Fallot’s trilogy, endocardial cushion defect, VSD with pulmonary hypertension, etc.
Besides this, it can also be seen in apical myocardial infarction and straight back
syndrome. The ECG changes are:
• S waves in leads I, II and III.The depth of S wave is maximum in lead II.The
depth of S wave should be greater than the preceding R wave in at least one of
the three leads. (Remember in LAHB, the maximum depth of S wave is in
lead III.)
• The QRS axis is in northwest region. It is usually within −90° to −150°.
338
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25 ECG inMiscellaneous Clinical Conditions
Tips and Tricks
• Sinus tachycardia is the commonest ECG manifestation of acute pulmonary
embolism.
• SI, QIII, TIII is specic ECG change in acute pulmonary embolism.
• P pulmonale is typically seen in COPD with pulmonary hypertension.
• If you nd J wave, it may be due to hypothermia.
• If you nd northwest axis, look for SI, SII, SIII syndrome. However, it is
extremely rare. Remember: Rare diagnosis is rarely correct.
Self-Assessment Questions
1. Sinus tachycardia is common in ECG of patient suffering from hyperthyroid-
ism.True or false?
2. ECG may show atrial brillation in thyroid storm. True or false?
3. COPD is associated with high amplitude QRS complexes in ECG.True or false?
4. J waves are seen in hypothermia. True or false?
5. SI, QIII, TIII pattern is seen in ECG of acute pulmonary embolism. True
or false?
6. Which ECG nding is commonly seen in hyperthyroidism?
a. Prolonged P-R interval b. Sinus tachycardia c. Right axis deviation d.
Sinus bradycardia
7. Which ECG nding is commonly observed in COPD?
a. Left axis deviation b. Prolonged P-R interval c. Peaked P waves d.
Prominent R waves in precordial leads
8. ECG of patient suffering from hypothermia is likely to show:
a. J waves b. Prolonged P-R interval c. Sinus bradycardia d. All of
the above
9. ECG of patient suffering from myxoedema is likely to show:
a. Low voltage complex b. Prolonged P-R interval c. Sinus bradycardia d.
All of the above
10. Northwest QRS axis is seen in:
a. COPD b. SI, SII, SIII syndrome c. Hypothermia d. CVA
25.7 SI, SII, SIII Syndrome
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Case Studies
1. A 55-year-old lady was admitted with fracture shaft femur of left leg. She was
operated. On third postoperative day, she suddenly complained of chest pain and
became breathless. After about ve minutes she had a bout of haemoptysis. On
examination, her pulse rate was 128bpm, blood pressure was 86/60 mmHg.
There was loud P2. There were bilateral crepitations with decreased breath
sounds. There was tenderness in left calf muscle. Her ECG is given in Fig.25.7.
What is your diagnosis?
III III
25 mm/s. 10 mm = 1 mV
V1 V2
25 mm/s. 10 mm = 1 mV
Fig. 25.7 Interpret the ECG
V3
aVR
V4
aVL
V5
aVF
V6
340
25 mm/s. 10 mm = 1 mV
Lead II 25 mm/s. 10 mm = 1 mV
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25 ECG inMiscellaneous Clinical Conditions
2. A 50-year-old gentleman presented in emergency department with severe breath-
lessness and cough for last six hours. He is a chronic smoker. He has history of
hypertension and dyslipidaemia. He is on irregular treatment. Patient had dyspnoea. His pulse rate was 110bpm, blood pressure was 150/90mmHg, afebrile.
Chest examination revealed bilateral wheeze and crepitations with decreased
breath sound. The chest was barrel shaped. Heart sounds were normal except for
loud P2. Examine his ECG given in Fig.25.8 and make your diagnosis.
3. A 70-year-old gentleman was brought to the emergency department in a drowsy
state by his relatives at around 6 AM on a very cold day. He was partially
responding to verbal commands. His pulse was irregularly irregular and rate was
about 50 bpm and blood pressure was 84/66 mmHg. His ECG is given in
Fig.25.9. What is your diagnosis?
IIIIII
25 mm/s. 10 mm = 1 mV
V1 V2
Fig. 25.8 Interpret the ECG
Fig. 25.9 Interpret the ECG
V3
aVR
V4
aVL
V5
aVF
V6
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