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Syncope and the ECG

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Syncope and the ECG

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Syncope and the ECG

  1. 1. Dan Pixley 2018
  2. 2.  common; about 3–5% of ED visits and 1–6% of hospital admission  underlying cause: unknown (34-36%), vasovagal (18-21%), and cardiac (9.5-18%)  4 Diagnostic categories: ◦ Reflex-mediated ◦ Orthostatic ◦ Cardiac ◦ Cerebrovascular
  3. 3.  is a rule for evaluating the risk of adverse outcomes in patients presenting with syncope  CHESS ◦ Congestive heart failure ◦ Hematocrit < 30% ◦ Abnormal ECG ◦ Shortness of breath ◦ Triage systolic blood pressure < 90  96% sensitive and 62% specific  99.2% negative PV, 24.8% PPV
  4. 4.  Can Quick BRAD Walk Home ◦ Conduction blocks ◦ Long/ short QT ◦ Brugada ◦ RV infarction/ coronary ischaemia ◦ ARVD ◦ DCM ◦ WPW ◦ Hypertrophy (HCM or LVH due to AS)
  5. 5.  Age  History of arrhythmias, IHD, structural Heart disease  Diabetes  newly abnormal ECG  Elevated troponin level  History of Cardiac disease  Patients with pacemakers or other cardiac devices: ◦ have a high index of suspicion in these patients for arrhythmia and / or cardiac device malfunction ◦ All patients with pacemakers with unexplained collapse must be admitted until such time as their pacemaker can be checked ◦ Most devices can be interrogated for a record of significant arrhythmia over an extended period of weeks
  6. 6.  65 year old male with history of hypercholesterolaemia, HTN and T2DM presents with epigastric pain. What do we do?
  7. 7.  74 year old male with history of COPD, HTN and IHD presents with sharp/central chest pain of 30 mins duration and then a short syncope. HR 72, BP 105/62,sats 95% RA What do we do? Image from ref 2
  8. 8.  40-50% of all myocardial infarctions  Up to 40% of patients with an inferior STEMI will have a concomitant right ventricular infarction ◦ can develop severe hypotension in response to nitrates and generally have ◦ develop significant bradycardia due to second-or third-degree AV block  RV infarction suggested by - ST elevation in lead III > lead II - Presence of reciprocal ST depression in lead I - Signs of right ventricular infarction: STE in V1 and V4R
  9. 9.  48 year old female with a history of IHD presents with left sided chest pain radiating to jaw. Not relieved by normal GTN What do we do? Image from ref 1
  10. 10.  Widespread horizontal ST depression, most prominent in leads I, II and V4-6  ST elevation in aVR ≥ 1mm Requires Urgent referral to Cardiology for PCI
  11. 11.  65 year old male with history of T2DM and smoking self presents after an episode of chest pain + syncope. The chest pain resolved 30 mins prior to arrival in ED
  12. 12.  pattern of deeply inverted or biphasic T waves in V2-3,  specific for a critical stenosis of the left anterior descending artery (LAD)  Patient may be pain free by the time ECG is taken but they are at extremely high risk for extensive anterior wall MI within the next few days to weeks.  Require PCI
  13. 13.  35 year old male with nil medical history presents after his bucks party with palpitations.
  14. 14.  most common sustained arrhythmia  Lifetime risk over the age of 40 years is ~25%  Ischaemic heart disease  Hypertension  Valvular heart disease (esp. mitral stenosis / regurgitation)  Acute infections  Electrolyte disturbance (hypokalaemia, hypomagnesaemia)  Thyrotoxicosis  Drugs (e.g. sympathomimetics)  Pulmonary embolus  Pericardial disease  Acid-base disturbance  Pre-excitation syndromes  Cardiomyopathies: dilated, hypertrophic.  Phaeochromocytoma Reference 2
  15. 15.  47 year old accountant presents SOB pus presyncopal
  16. 16.  The atria contract at 300 beats per minute causing a ‘seesaw’ baseline. Beats are transmitted with a 2:1, 3:1 or 4:1 block, leading to ventricular rates of 150, 100 and 75 BPM respectively.  Vagal manouvers +/- Adenosine. A flutter will not usually respond to this. This will often give a transient period of increased AV block during which flutter waves may be unmasked. Reference 2
  17. 17.  82 year old male with COPD presents with fevers and green sputum.
  18. 18.  occurs in respiratory disease and reflects an aberrant foci of atrial excitation  typically a transitional rhythm between frequent premature atrial complexes (PACs) and atrial flutter / fibrillation  At least 3 distinct P-wave morphologies in the same lead  Thought to be a result of: ◦ Right atrial dilatation (from cor pulmonale) ◦ Increased sympathetic drive ◦ Hypoxia and hypercarbia ◦ Beta-agonists Reference 2
  19. 19.  65 year old man with a history of ischaemic heart disease is found unresponsive. What do we do?
  20. 20.  65 year old man with a history of ischaemic heart disease presents with SOB What do we do?
  21. 21.  Treatment of FBI: Unstable ◦ DC Cardioversion!  Stable ◦ IV chemical cardioversion e.g procainamide ◦ Avoid all AV nodal blockers!  Adenosine  Verapamil  Diltiazem  Beta-blockers  Digoxin  Amiodarone (has both beta-blocker and Ca-channel blocker properties)
  22. 22.  50 year old lady comes to the emergency department from her husband’s funeral with a sensation of ‘fluttering’ in her chest. She is feeling very anxious. What do we do?
  23. 23. 2 main types. AVNRT (left) and AVRT (right) Reference 2
  24. 24.  60 year old male presents with chest pain and suddenly stops talking during ECG What do we do?
  25. 25.  18 year old male signs up for the army and has a routine ECG
  26. 26.  Due to a mutation in the cardiac sodium channel gene  Type 1 Coved ST segment elevation >2mm in >1 of V1-V3 followed by a negative T wave  Type 2: 2mm of saddleback shaped ST elevation  Diagnosis must be coupled with clinical criteria: VF, FHX sudden death, Syncope  The only proven therapy is an implantable cardioverter – defibrillator (ICD)
  27. 27.  24 year old male collapses 1 minute in to his run. Has happened previously
  28. 28.  Number one cause of sudden cardiac death in young athletes. Annual mortality is estimated at 1-2 %  Left ventricular hypertrophy (LVH), occurring in the absence of any inciting stimulus such as hypertension or aortic stenosis  ECG Signs: ◦ LVH ◦ deep, narrow (“dagger-like”) Q waves in the lateral (V5- 6, I, aVL) and inferior (II, III, aVF) leads ◦ P mitrale ◦ T wave inversion laterally in apical HCM
  29. 29.  A 25 year old man presents with a collapse which occurred as he was playing in a football match. He has suffered episodes of fainting in the past
  30. 30.  PR interval <120ms  Delta wave – slurring slow rise of initial portion of the QRS  QRS prolongation >110ms  Look for T waves in anterior leads. Pre- excitations simulates RVH
  31. 31. 16 year old boy presents to clinic after an episode of syncope
  32. 32.  Calculate the QTc ◦ Bazetts formula (med calc) ◦ Fredericas formula  The QT shortens at faster heart rates  The QT lengthens at slower heart rates  Bazetts formula not as accurate outside HR 60-100BPM  QTc is prolonged if > 440ms in men or > 460ms in women  QTc > 500 is associated with increased risk of torsades de pointes  A useful rule of thumb is that a normal QT is less than half the preceding RR interval
  33. 33.  Causes:  Hypokalaemia  Hypomagnesaemia  Hypocalcaemia  Hypothermia  Myocardial ischemia  Post-cardiac arrest  Raised intracranial pressure  Congenital long QT syndrome  DRUGS
  34. 34.  K+ channelopathy  QTc (<300-350)  Short QT interval  Lack of the normal changes in QT interval with heart rate  Peaked T waves, particularly in the precordial leads  Short or absent ST segments  Episodes of atrial or ventricular fibrillation
  35. 35. 20 year old male presents with palpitations
  36. 36.  inherited disorder associated with paroxysmal ventricular arrhythmias and sudden cardiac death.  Epsilon wave (most specific finding, seen in 30% of patients)  T wave inversions in V1-3 (85% of patients)  Slurred S wave (V1-3): 95% of patients  Localised QRS widening of 110ms in V1-3  Paroxysmal episodes of ventricular tachycardia
  37. 37.  1st degree:  2nd degree ◦ Mobitz 1 Mobitz 2 3rd Degree
  38. 38.  60 year old male presents to ED after syncope. History of CKD.
  39. 39.  Increased extracellular potassium reduces myocardial excitability.  leads to suppression of impulse generation by the SA node and reduced conduction system, resulting in bradycardia, conduction blocks and ultimately cardiac arrest.
  40. 40.  Serum potassium > 5.5 mEq/L is associated with repolarization abnormalities: ◦ Peaked T waves  Serum potassium > 6.5 mEq/L is associated with progressive paralysis of the atria: ◦ Lengthen PR, P wave widens and flattens  Serum potassium > 7.0 mEq/L is associated with conduction abnormalities and bradycardia: ◦ Prolonged QRS interval with bizarre QRS morphology ◦ High-grade AV block with slow junctional and ventricular escape rhythms ◦ Sinus bradycardia or slow AF ◦ Development of a sine wave appearance (a pre-terminal rhythm)  Serum potassium level of > 9.0 mEq/L causes cardiac arrest due to:  Asystole  Ventricular fibrillation  PEA with bizarre, wide complex rhythm
  41. 41.  26 year old male with Conns syndrome presents with muscle weakness and pains Hypokalaemia
  42. 42.  A 29 year old BIBA in arrest. Initial ECG done prior to arrest was this
  43. 43.  ECG done 2 weeks ago by GP was found. She had presented with chest pain.
  44. 44.  An 18 year old lady is found collapsed at home. When you see her she has a GCS of 10 and you notice that her pupils are dilated.
  45. 45.  A,B,C,D,E (ventilation may be required) ◦ Bloods including paracetamol level; Activated charcoal if within 8hrs of ingestion  Sodium bicarbonate (50ml of 8.4%) ◦ Give if any arrhythmia or QRS widening  Further options: ◦ If seizures: benzodiazepines
  46. 46. 55 year old male with hx of PCKD presents with GCS 3
  47. 47.  82 year old male presents with syncope
  48. 48. 84 year old male with hx of CCF plus IHD presents post syncope
  49. 49.  Important ECG findings in Syncope: ◦ Paroxysmal or sustained dysrhythmia on monitoring in clinic ◦ Non-sinus rhythm of any sort ◦ Nonspecific intraventricular conduction delay (QRS > 100 ms without left or right bundle branch pattern) ◦ Left bundle branch block or left anterior or posterior hemiblock ◦ ECG signs of coronary ischemia ◦ Long QT syndrome - QTc > 440-450 msec in men or > 460 msec in women ◦ Brugada sign - right bundle branch block and anterior ST elevation ◦ Left ventricular hypertrophy in someone with no reason to have it and/or Q waves in II, III, aVF, V5, and V6 ◦ Pre-excitation syndromes (PR interval < 120 msec) with or without delta wave ◦ Can Quick BRAD Walk Home
  50. 50.  1. OME – Oxford Medical Education: ECGs and knowledge  2. Life in the fast lane – ECG diagnoses A-Z  3. Prospective validation of the San Francisco Syncope Rule to predict patients with serious outcomes. AAEM 2013. Image from ref 1

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