Electrocardiographic Changes in Patients with Acute Stroke outlines ECG changes that can occur in patients experiencing acute stroke and their implications. ECG changes are classified based on the cause of stroke, as a direct consequence, or from a pre-existing cardiac condition. Common changes seen include T-wave inversions, ST-segment elevations or depressions, and QT prolongation. Abnormal ECGs have been associated with worse prognosis and higher mortality. Potential pathophysiological mechanisms include neural myocardial stunning, autonomic nervous system imbalances, and catecholamine-mediated injuries. Recognition of stroke-related ECG changes is important for clinical diagnosis and management.

1. Electrocardiographic Changes
in Patients with Acute Stroke
Ade Wijaya, MD
November 2017

2. Outline:
• Introduction
• Classification
• Common ECG changes in acute stroke
• ECG and Prognosis
• Pathophysiology
• Clinical implication
• Summary

3. Introduction
• Reported since 1947
• The brain–heart connection was described early in the 20th century when
Levy showed that changes in central nervous system (CNS) metabolism
influenced cardiac function
• The role of the hypothalamus in controlling cardiac rhythm
Byer E, Ashman R, Toth LA: Electrocardiograms with large upright T waves and long QT intervals. Am Heart J 1947;33:796–806.
Burch GE, Meyers R, Abildskov JA: A new electrocardiographic pattern observed in cerebrovascular accidents. Circulation 1954;9: 719–723.
Wasserman F, Choquette G, Cassinelli R, Bellet S: Electrocardiographic observations in patients with cerebrovascular accidents; report of 12 cases. Am J Med Sci 1956;231:502.
Levy A. The exiting causes of ventricular fibrillation in animals under chloroform anesthesia. Heart 1913; 4:319–78.
Boeles J, Korteweig G, Ten Cate J. Influence of stimulation of subcordal areas on elctrocardiogram. J Neurophysiol 1957; 20: 100–7.
Weinberg S, Fuster J. Electrocardiographic changes produced by localized hypothalamic stimulations. Ann Intern Med 1960; 53: 332–41.

4. Classification
• The cause of stroke
• Direct consequence of stroke
• Pre-existing cardiac disorder
Khechinashvili, G., & Asplund, K. (2002). Electrocardiographic changes in patients with acute stroke: a systematic review.Cerebrovascular diseases, 14(2), 67-76

5. Common ECG Changes in Acute Stroke
Khechinashvili, G., & Asplund, K. (2002). Electrocardiographic changes in patients with acute stroke: a systematic review.Cerebrovascular diseases, 14(2), 67-76
Purushothaman, S., Salmani, D., Prarthana, K. G., Bandelkar, S. M. G., & Varghese, S. (2014). Study of ECG changes and its relation to mortality in cases of cerebrovascular accidents. Journal of
Natural Science, Biology, and Medicine, 5(2), 434–436. http://doi.org/10.4103/0976-9668.136225

6. ECG and Stroke Prognosis
Mortality in stroke types and its relation with electrocardiogram (ECG) changes Relationship of mortality with abnormal electrocardiogram (ECG) in stroke patients
Purushothaman, S., Salmani, D., Prarthana, K. G., Bandelkar, S. M. G., & Varghese, S. (2014). Study of ECG changes and its relation to mortality in cases of cerebrovascular accidents. Journal of
Natural Science, Biology, and Medicine, 5(2), 434–436. http://doi.org/10.4103/0976-9668.136225

7. Pathophysiology
• Neural myocardial stunning,
• Changes in autonomic nervous system,
• Catecholamine-mediated injuries.
• Some have attributed these to lesions in the insular cortex, which can lead to cardiac
abnormalities such as ischemic-like changes, arrhythmias, and even myocytolysis.
• This sometimes makes it difficult to make a diagnosis of heart disease in the
presence of acute stroke.
Familoni OB, Odusan O, Ogun SA. The pattern and prognostic features of QT intervals and dispersion in patients with acute ischemic stroke. J Natl Med Assoc. 2006;98:1758–62.
Oppenheimer S. Cerebrogenic cardiac arrhythmias: Cortical lateralization and clinical significance. Clin Auton Res. 2006;16:6–11.

8. Implications for Clinical Practice
• In patients with SAH, ischemic-like ECG changes are seen in almost three
quarters of patients irrespective of the presence or absence of previous
cardiac disease
• ECG changes in patients with ischemic stroke or ICH most often represent
preexisting ischemic heart disease
• Stroke patients with elevated TnT have a less favourable short-term outcome
than other stroke patients
Khechinashvili, G., & Asplund, K. (2002). Electrocardiographic changes in patients with acute stroke: a systematic review.Cerebrovascular diseases, 14(2), 67-76
Fure, B., Bruun Wyller, T., & Thommessen, B. (2006). Electrocardiographic and troponin T changes in acute ischaemic stroke. Journal of internal medicine, 259(6), 592-597.

9. Summary
• Brain – Heart Connection
• Various hypothetical mechanisms
• Related with prognosis

10. THANK YOU