The Wavy triple an electrocardiographic sign (Yasser’s sign) is a new diagnostic sign seen in 97.3% (36 cases) of hypocalcemia. Dramatic improvement of both clinical manifestation and the new electrocardiographic sign simultaneously after calcium replacement had happened.

1. Cardiology & Emergency Medicine-
2021 August 20-21, 2021
Canada

2. Elsayed
MB Bch, PGDip Cardiology (Middlesex
University, RILA)
Researcher and author
Critical Care Unit
Work: Egyptian Ministry of Health (MOH)
Damietta, Damietta Health Affairs

3. My greetings

4. Wavy triple an
electrocardiographic sign
(Yasser’s sign)

6. • Discovery and historical bit
• Understanding the description and the analysis for this sign of Wavy triple
sign
• The hypocalcemia and Wavy triple sign; examples
• The study data and statistics
• Mechanisms of Wavy triple sign
• Differential Diagnosis
• How to deal with it? (Management)
• Summary
• Conclusion and Recommendations

7. Issue Definition
Title Wavy Triple An Electrocardiographic Sign
(Yasser’s Sign) in Hypocalcaemia-A Novel
Diagnostic Sign
Estimated Enrollment 37 participants
Study Type Observational
Observational Model Case-only
Time Retrospective
Study Start Date March 12, 2018
Estimated Study Completion
Date
Jun 8, 2019
Analytic method Comparative using percentage %
Table 1- showing remarks of the study method and data.

8. Discovery

9. 1. History

10. 2. Principles of the Wavy
triple an
electrocardiographic sign
(Yasser’s sign)

11. • The analysis for this sign in
the author interpretations are
based on the following;

12. 1. Different successive three beats in
the same lead are affected.

13. 2. All ECG leads can be implicated.

14. 3. An associated elevated beat is
seen with the one of the successive
three beats, a depressing beat with
the second beat, and an isoelectric
ST-segment in the third one.

15. 4. The elevated beat is either
accompanied by ST-segment
elevation or just an elevated beat
above the isoelectric line.

16. 5. Also, the depressed beat is either
associated with ST-segment
depression or just a depressing beat
below the isoelectric line.

17. 6. The configuration for depressions,
elevations, and isoelectricities of ST-
segment for the subsequent three
beats are variable from case to case.
So, this arrangement is non-
conditional.

18. 7. Mostly, there is no participation
among the involved leads. The
author intended that is not
conditionally included in an especial
coronary artery for the affected
leads.

19. Let me to introducing examples for understanding

20. Case No. 1

21. A 28-year-old married Egyptian housewife
female patient presented to ED with
carpopedal spasm. The patient gave a recent
history of poor nutritional status due to
psycho-social troubles. Two-calcium
gluconate ampoules 10 ml 10% over IV over
20-minutes were taken. Complete clinical and
ECG recovery (Figure 2).

22. Figure 2; A-ECG tracing of the presentation showing “Wavy triple sign” in Leads: I, II, III, aVF, aVR, and V1-6. B-ECG tracing after calcium injection
showing the disappearance of the previous sign.
(Red arrows =elevated beats, blue arrows = isoelectric beats, and black arrows =depressed beat).

23. Case No. 2

24. A 26-year-old married Egyptian housewife
female patient presented to the POC with
carpopedal spasm and psychogenic HVS. The
patient gave a recent history of poor
nutritional status due to poor status. One Ca
gluconate amp 10 ml 10% over IV over 10
minutes was taken. Complete clinical and
ECG recovery (Figure 3).

25. Figure 3; A-ECG tracing of the presentation showing “Wavy triple sign” in: II, III, aVF, and V6 Leads. B-ECG tracing after Ca injection showing the
disappearance of the previous sign.
(Red arrows =elevated beats, blue arrows = isoelectric beats and black arrows =depressed beat).

26. Case No. 3

27. A 63-year-old married Egyptian male farmer
patient presented to the ED with carpopedal
spasm. The patient gave a recent history of poor
nutritional status due to deprivation. The patient
was admitted in the internal ward as tetany. Two
Ca gluconate ampoules 10 ml 10% over IV over
20-minutes were taken. Complete clinical and
ECG recovery (Figure 4).

28. Figure 4; A-ECG tracing of the ED presentation showing “Wavy triple sign” in: I, II, aVF, aVR, aVL, and V4 Leads. B-ECG tracing of IW copy before Ca
administration showing movable changes of the wavy sign in II, III, aVL, aVF, and V6 Leads. C-ECG tracing after Ca injection showing the disappearance of
the previous sign (Movable phenomenon).
(Red arrows =elevated beats, blue arrows = isoelectric beats, and black arrows = depressed beats).

29. Case No. 4

30. A 30-year-old married Egyptian housewife
female patient presented to the ED with
carpopedal spasm and psychogenic HVS. The
patient gave a recent history of socio-familial
stress. The patient was admitted to the IW as
tetany. Two Ca gluconate ampoules 10 ml 10%
over IV over 20 minutes were taken. Complete
clinical and ECG recovery (Figure 5).

31. Figure 5; A-ECG tracing of the ED presentation showing “Wavy triple sign” in V1-4 Leads. (B-ECG tracing after Ca injection showing the
disappearance of the previous sign.
(Red arrows =elevated beats, blue arrows = isoelectric beats, and black arrows = depressed beats).

32. Case No. 5

33. A 42-year-old married Egyptian housewife
female patient presented to the POC with
carpopedal spasm and psychogenic HVS. The
patient gave a recent history of socio-familial
stress. The patient was admitted to IW as
tetany. One Ca gluconate ampoule 10 ml 10%
over IV over 10 minutes was taken. Complete
clinical and ECG recovery (Figure 6).

34. Figure 6; A-ECG tracing of the POC presentation showing “Wavy triple sign” in V3, V4, and V6 Leads. B-ECG tracing after Ca injection
showing the disappearance of the previous sign.
(Red arrows =elevated beats, blue arrows = isoelectric beats, and black arrows = depressed beats).

35. Case No. 6

36. A 37-year-old married, housewife, female, Egyptian
patient presented to the ED with choking, rapid difficult
breathing, inability speaking, and a sense of suffocation.
She was recently exposed to socio-familial stress. The
patient was admitted to the IW as tetany, laryngospasm,
and severe hypocalcemia. Two Ca gluconate ampoules
(10 ml 10% over IV over 20 minutes) were given as an
emergency dose. Maintenance therapy with IVI Ca
gluconate ampoules (10% with the rate; 0.5 mg/kg/hour
over IV over 6 hours) was the infused.

37. Figure 7; A-ECG tracing of the POC presentation showing NSR with widespread Wavy triple sign of hypocalcemia in ten leads of ECG with VR; 82 bpm. B-
ECG tracing was taken within 1.30 hours after 2 amp of IV calcium therapy showing nearly normalization of all above ECG findings.
Red arrows indicate an elevated beat. Green arrows indicate a depressing beat. Blue arrows indicate isoelectric beat.

38. Case No. 7

39. A 30-year-old married Egyptian housewife female
patient presented to the ED with carpopedal spasm
and psychogenic HVS. The patient gave a recent
history of socio-familial stress. The patient was
admitted to the ICU as tetany with chest pain. TwoCa
gluconate ampoules 10 ml 10% over IV over 20
minutes were taken. Complete clinical and ECG
recovery (Figure 8).

40. Figure 8; A-ECG tracing of the ED presentation showing “Wavy triple sign” in V1-6 Leads. depressed beats). B-ECG tracing after Ca
injection showing the disappearance of the previous sign.
(Red arrows =elevated beats, blue arrows = isoelectric beats, and black arrows =

41. Case No. 8

42. A 58-year-old married Egyptian male carpenter patient
presented to the ED with carpopedal spasm. The patient
gave a history of liver cirrhosis with HCC and
malnutrition. The patient was admitted to the IW for
both tetany and chronic liver disease. One Ca gluconate
amp 10 ml 10% over IV over 10 minutes was taken.
Complete clinical and ECG recovery (Figure 9).
Management of CLD was given according to the
standard guidelines.

43. Figure 9; A-ECG tracing of the ED presentation showing “Wavy triple sign” in V3, V4, and V6 Leads. B-ECG tracing after calcium
injection showing the disappearance of the previous sign-in V4,6 But there is an artifact in V3, So, the author can’t decide the effect.
(Red arrows =elevated beats, blue arrows = isoelectric beats, and black arrows = depressed beats).

44. Case No. 9

45. A 75-year-old married Egyptian female housewife
patient was admitted to the ICU with a CVA with
infarction, HTN, and HVS. One Ca gluconate ampoule 10
ml 10% over IV over10 minutes was taken. Electrolytes
profile and ABG were checked during HVS episodes.
Complete resolution of the ECG changes had happened
(Figure 10).

46. Figure 10; A and B-ECG tracing during hyperventilation episodes showing “Wavy triple sign” in: II, III,aVF, and V4-6 Leads. C-ECG tracing
after CA injection showing the disappearance of the previous sign.
Red arrows =elevated beats, blue arrows = isoelectric beats, black arrows =depressed beats

47. Case No. 10

48. A 29-year-old married housewife Egyptian female
patient presented to the POC with perioral parethesia,
extremities tingling, non-specific chest pain, and
fatigue. The patient gave a recent history of poor
nutritional status due to heavy work. Trousseau and
Chvostek's signs sign were elicited. The patient was
managed with an oral Ca capsule (600 mg, single daily
dose). The ECG was done within 3 days of being given
oral calcium. Complete resolution of both clinical and
ECG changes had happened (Figure 11).

49. Figure 11; A-ECG tracing of the presentation showing “Wavy triple sign” in: V2, V5, and V6 Leads. B-ECG tracing; 3 days after oral
calcium showing the disappearance of the previous sign.
(Red arrows =elevated beats, blue arrows = isoelectric beats, black arrows = depressed beats).

50. Case No. 11

51. A 13-year-old single Egyptian student female patient
presented to the POC with carpopedal spasm and
idiopathic HVS. The patient was managed as tetany with
chest pain. The only ECG; II, aVF, and V1-6 leads were
involved. This case is exceptional for the study. “Wavy
triple sign” is replaced with: “Wavy double sign”. So,
there are only two affected beats; but not the three like-
Wavy triple sign. Two Ca gluconate ampoules 10 ml 10%
over IV over 20 minutes were taken. Complete clinical
and ECG recovery (Figure 12).

52. Figure 12; A-ECG tracing of the presentation showing “Wavy triple sign” in Leads: II, aVF, and V1-6. B-ECG tracing 3 days after
Ca injection showing the disappearance of the previous sign.
(Red arrows =elevated beats, blue arrows = isoelectric beats, black arrows = depressed beats).

53. Case No. 12

54. A 42-year-old married, male, car-painter, Egyptian,
heavy smoker patient presented to the ED with
atypical severe twisting anginal chest pain, ↓Ca++,
↓K+, and ↓Na+.

55. Figure 13: A-tracing; an initial ECG emergency on ICU admission showing widespread “U”-waves thorough ECG (red arrows),
Tee-Pee sign (green arrows), Wavy double sign of hypocalcemia (Yasser’s sign; blue arrows), evidence of RBBB (brown arrows),
and sinus bradycardia of VR;48 bpm. B-tracing; was taken within 3.18 hours of A-tracing and after starting the anti-ischemic
measures, IVI of K+ therapy, and 3 amps of IV atropine. It nearly showed the same of A-tracing but with marked sinus
bradycardia with VR; 36 bpm. C-tracing; was taken within 9.33 hours of A-tracing and immediately after 2 amp of IV CA
showing nearly normalization of all above ECG findings but with still evidence of RBBB (brown arrows ) and VR;68 bpm.

56. The study data and statistics

57. Table 1: Summary of the history, clinical, and management Data for all the study cases.
• * (no follow up with ECG), Addict**; Marijuana, BP; Blood Pressure, Ca; Calcium, CLD; Chronic liver diseases, CVA; Cerebrovascular
Accident , DKA; Diabetic ketoacidosis, ECG; Electrocardiography, F; Female, HVS; Hyperventilation syndrome, K+; Potassium, Mg++;
Magnesium, M; Male, Malnut: Malnutrition, Na+; Sodium, Pregn.; Pregnancy, RA; Risk factor, RR; Respiratory rate

58. Table 2: Laboratory data for the cases of the first group
• ABG ; arterial blood gases, BP; blood pressure, Ca++; calcium, CLD; chronic liver disease, CVA; cerebrovascular accident, D;
deficiency, DKA; diabetic ketoacidosis; diagnosis, HR; heart rate , HVS; hyperventilation syndrome, MA** :metabolic acidosis, Na+;
sodium K+; potassium, Mg++; magnesium, RR; respiratory rate, RA; respiratory alkalosis, RBS; random blood sugar

59. Some statistics

60. Age

61. • Age averages in the study; Mean: 38.4, Median: 33, Mode: 30.

62. Sex

63. • Sex in both groups: Female (F) 72.97% (27 cases) vs. Male (M)
27.03% (10 cases)

64. Complaints

65. • The main complaints in the study were carpopedal spasm (89.19 %)
vs. Parathesia and tingling (8.11%), and hyperventilation syndrome
(2.7%) (Figure 13).

66. Figure 13; showing the main complaints in the study.

67. The associated risk factors (RF)
and etiology

68. • The associated risk factors (RF) and etiology in the study;
• HVS: 45.95% (17 cases)
• Malnutrition: 24.32% (9 cases)
• Combined RF:
• Malnutrition + CLD: 5.41% (2 cases)
• Malnutrition + Elderly: 2.7% (1 case)
• HVS+ DKA: 2.7% (1 case)
• HVS+ Coffee: 5.41% (2 cases)
• HVS+ CVA: 2.7% (1 case)
• HVS+ Pregnancy: 5.41% (2 cases)
• HVS+ Marijuana: 2.7% (1 case)
• DKA+ CLD: 2.7% (1 case) (Figure 14).

69. Figure 14; showing the associated risk factors (RF) and etiology in the study.

70. The final diagnosis

71. • Manifested tetany: 89.19% (33 cases)
• Latent tetany: 8.11% (3 cases)
• Non-classified (During cerebrovascular
accident): 2.7% (1 case) (Figure 15).

72. Figure 15; showing the final diagnosis for hypocalcemia in the study.

73. Positivity and Wavy triple sign

74. • The wavy triple sign is a positive and triple
sign in 97.3% (36 cases) but it is only wavy
double in 2.7% (case No. 13). So, the percent
of the sign in the study in both groups: 97.3%
wavy triple (36 cases) vs. 2.7% of wavy double
(one case; case No. 13)

75. Number of affected ECG leads

76. • Averages number of affected ECG leads (No.
of leads); Mean: 4.13, Median: 3, Mode: 3,
Max: 10, Min: 1.

77. The frequency for the number of
affected ECG leads

78. Figure 16 showing the frequency for the number of affected ECG leads in the study.

79. Number of affected ECG leads vs.
the level of ionized Ca++

80. Figure 17 showing the number of affected ECG leads vs. the level of ionized Ca++ in the first group.

81. Mechanisms of Wavy triple sign

82. • The mechanisms of Wavy triple sign are
unknown
• The wavy movements in the myocardium
or coronaries during tetany have suggested an
explanation. These need further
investigations.

83. Differential Diagnosis (DD)

84. • Coronary artery spasm (CAS) and IHD are
possible differential diagnosis. But, in CAS
and IHD; all beats of affected lead either
regular depressed ST-segments or regular
elevated ST-segments.

85. Figure 18 Serial ECG tracings for a 33 female housewife after injected oral sertiraline tablet (50mg) in the presence of malnutrition
and psychological troubles presented to POC with tetany and HVS. A-tracing was done on the presentation showing both Wavy triple
(arrows of different color) and ischemic evidence (purple arrows). A-tracing was done after injection of 2 Ca++ amp. and O2
inhalation set showing normalization of the above changes. Red arrows =elevated beats, blue arrows = isoelectric beats, black arrows
=depressed beats.

86. Management of Wavy triple sign

87. • Essential points are considered in the management of Wavy
triple sign
• Serial ECG tracings
• The risk
• The course
• The clinical status
• Wavy triple sign can be treated as a case by case according to
the above considerations.

88. Summary

89. • The principles of “Wavy triple an electrocardiographic sign (Yasser sign) in hypocalcemia”
and their interpretations are depending on the following:
• Different subsequent three beats in the same lead are involved.
• Different leads may be affected.
• Mostly, there is no sharing part among the involved leads. The author intended that is
not conditionally included an especial coronary artery for the affected leads.
• An associated elevated beat is seen with the first of the subsequent three beats,
depressed beat with the second beat, and isoelectric ST segment in the third one.
• The elevated beat is either associated with ST-segment elevation or just elevated beat
above the isoelectric line. Also, the depressed beat is either associated with ST-segment
depression or just a depressing beat below the isoelectric line.
• The arrangement for depressions, elevations, and isoelectricities of ST-segment for the
subsequent three

90. beats are variable from case to case. So, this arrangement is non-conditional.
• The wavy curve for the subsequent three beats from depressions, elevations, and
isoelectricities are noticed and prescribed (Figure 1).
• The wavy movements in the myocardium or coronaries during tetany have suggested an
explanation. These need further investigations.
• Variable but segmental ECG leads are involved.
• The extent and severity of ECG changes are related to serum calcium level in the
investigated group.
• Tetany and latent hypocalcemia are included. Manifested tetany was the commonest
final diagnosis (89.19 %).
• Hyperventilation syndrome (45.95%) and malnutrition (24.32%) are the most common
risk factors.
• Carpopedal spasm was the main complaint (89.19 %).
• The Mean number of affected electrocardiographic leads: 4.13, Max.:10, and Min.:1).

91. • Dramatic improvement of both clinical manifestation and the new electrocardiographic
sign simultaneously after calcium replacement had happened.
• Parenteral or oral calcium preparation was supplied.
• “Wavy triple an electrocardiographic sign” is a novel sign in hypocalcemia not recorded
before.
• “Wavy triple an electrocardiographic sign” is a novel specific diagnostic ECG sign for
hypocalcemia if compared with the old traditional non-specific ECG signs.
• “ Wavy triple sign” is a positive and triple sign in 97.3% (36 cases) but it is only double in
2.7% (1 case).
• “Wavy triple an electrocardiographic sign” can be used as a therapeutic guide in cases of
hypocalcemia.
• Coronary artery spasm (CAS) is a possible differential diagnosis. But, in CAS; all beats of
affected lead either regular depressed ST-segments or regular elevated ST-segments.

92. Conclusion and Recommendatios

93. • “Wavy triple an electrocardiographic sign
(Yasser’s sign)” is a new specific diagnostic sign
seen in 97.3% of the cases of hypocalcemia.
• “Wavy triple an electrocardiographic sign” can be
used as a therapeutic guide in the cases of
hypocalcemia.
• Further investigations for the “Wavy triple an
electrocardiographic sign (Yasser sign)” for more
evaluation and assessment are recommended.

94. References

95. 1. Elsayed YMH. Wavy Triple an Electrocardiographic Sign (Yasser Sign)
in Hypocalcemia. A Novel Diagnostic Sign; Retrospective Observational
Study. EC Emergency Medicine and Critical Care (ECEC). 2019;3(2):1-2.
Available from: https://www.ecronicon.com/ecec/volume3-
issue12.php (Accessed Nov 6, 2019).
2. Elsayed YMH. Hypocalcemia-induced Camel-hump T-wave, Tee-Pee
sign, and bradycardia in a car-painter of a complexed dilemma: A case
report. Cardiac 2020;2(1):07. DOI :
https://doi.org/10.35702/card.10007

96. Thank you