(+)Amal Mattu, MD, FACEP

Associate Professor; Program Director,

Emergency Medicine Residency,
University of Maryland School of
Medicine, Baltimore, Maryland

Subtle ECG Manifestations of Deadly

Cardiac Disease: Thinking Outside
the Pine Box

The electrocardiogram is one of the basic tools

used to detect myocardial ischemia. The ED
physician is trained to look for ST-segment
changes and other flagrant manifestations of
myocardial ischemia, but there are other
indicators. All too often, subtle manifestations
of cardiac disease are missed with fatal
consequences. The speaker will review ECG
findings that could literally mean the difference
between life and death but are easily missed
unless you are specifically looking for them.

Identify subtle ECG manifestations with

potentially fatal outcomes if missed.
Provide an approach to the analysis of the ECG
that will assist in detecting myocardial disease.
Practice ECG analysis in a case-based format.

TU-23
9/28/2010
12:30 PM - 1:20 PM
Mandalay Bay Convention Center

(+)No significant financial relationships to disclose

Subtle ECG Manifestations
of Deadly Cardiac Disease

Amal Mattu, MD, FACEP

Program Director, Emergency Medicine Residency
Professor, Department of Emergency Medicine
University of Maryland School of Medicine
Baltimore, Maryland
amattu@smail.umaryland.edu
Case 1, ECG #1 (87 yo. man with nausea, diaphoresis, and pallor)

Case 1, ECG #2 (Baseline ECG)

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Amal Mattu, MD
 Case 2 (32 yo. man with chest pain and dyspnea)

Case 3 (38 yo. woman with positional chest pain)

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Amal Mattu, MD
Case 4 (42 yo. man with chest pressure, dyspnea, and cough)

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Amal Mattu, MD
 Stop!
Please do not look at
the answers to the
preceding cases yet!

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Amal Mattu, MD
I. Early Reciprocal Changes in Lead aVL

• The normal ECG shows an isoelectric ST-segment and upright T-wave in aVL
• An inverted T-wave in aVL is often found with inferior wall myocardial infarction
• Represents a “reciprocal change”
• Marriott — may precede the expected changes in inferior leads; may initially be
the only abnormality found on the ECG of a patient with acute inferior MI or
ischemia
• Major exceptions — downsloping ST-segment and inverted T-wave in aVL is normal
finding in patients with LVH and LBBB

II. Pulmonary Embolism Simulating Acute Coronary Syndrome

• Typical ECG findings
• SIQIII or SIQIIITIII
• RBBB or incomplete RBBB (often transient)
• Rightward axis
• T-wave inversions, especially in right precordial leads (V1-V3) + inferior leads
• Marriott and others: combination of T-wave inversions in right precordial and
inferior leads is highly specific for acute pulmonary hyptertension, pulmonary
embolism

• May also (less commonly) cause

• ST-segment depression or elevation in right precordial leads
• ST-segment depression in leads I or II
• ST-segment elevation in lead III

• Important point: PE often causes ECG changes that resemble cardiac ischemia
• Don’t just “rule out MI” when the ECG appears to show cardiac ischemia

III. Pericarditis vs. Acute MI

• Classic teaching
• Diffuse ST-segment elevation
• May be localized rather than diffuse
• But no reciprocal ST-segment depression! (except perhaps in aVR and V1)
• ST-segment elevation is concave upwards
• Beware that AMI may have similar ST-segment morphology
• ST-segment elevation that is convex upwards or horizontal strongly favors
AMI
• Additional pearl regarding ST-elevation
• STE II > STE III strongly favors acute pericarditis
• STE III > STE II very strongly favors acute MI
• PR-segment depression (downsloping)

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Amal Mattu, MD
 • Primarily present in viral pericarditis
• Often an early, transient finding
• PR-segment elevation in aVR
• May also be present in other diseases (e.g. AMI)
• Often absent in constrictive pericarditis
• Chest pain tends to be positional, pleuritic
• Beware that 16% of AMIs may present with positional or pleuritic pain!

• Factors strongly favoring AMI: ST-segment elevation that is convex upwards;

reciprocal ST-segment depression (in leads other than aVR and V1); known new Q-
waves
• Factors strongly favoring acute pericarditis: pronounced PR-segment depression
(downsloping) in multiple leads; friction rub

IV. Pericardial Effusion

• Large pericardial effusions are classically associated with

• Electrical alternans (usually involves QRS complex, but may involve the P-wave
and/or T-wave also)
• Present in < 30%
• Tachycardia
• May be blunted if the patient is taking cardiac medications
• Low voltage
• Defined as QRS amplitude in leads I + II + III < 15 mm OR QRS amplitude in
leads V1 + V2 + V3 < 30 mm
• Differential diagnosis also includes obesity, COPD, large pleural effusions,
severe hypothyroidism, end-stage cardiomyopathies, infiltrative diseases (e.g.
sarcoid, amyloid, scleroderma), massive MI
• New low voltage (compared to a recent ECG): think pericardial effusion or
pleural effusion
• Chest pain/pressure and dyspnea are most common
• Hypotension + JVD often when tamponade is present
• CXR usually demonstrates cardiomegaly (very sensitive but non-specific)
• Always consider the diagnosis in a patient with cardiopulmonary symptoms that
has tachycardia + low voltage!

V. Summary

• Reciprocal changes in lead aVL may be the first sign of inferior wall myocardial
ischemia
• Pulmonary embolism can cause ECG changes that simulate ACS
• Strongly consider PE when the ECG has inverted T-waves simultaneously in the
anteroseptal + inferior leads
• Don’t just “rule out MI” when the ECG demonstrates classic ischemic changes

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Amal Mattu, MD
• Pericarditis ECGs are often not “classic!”
• Very strongly favoring AMI
• Reciprocal changes
• Convex upwards or horizontal morphology of ST-segments
• New Q-waves
• Very strongly favoring pericarditis
• Pronounced PR-segment depressions in multiple leads
• Friction rub
• Pericardial effusion should be suspected in any patient with LV + tachycardia
• Especially if LV is new
• Recognition of these subtle abnormalities will make the difference between life and
death!
• Don’t rely on your cardiology consultants to make these diagnoses
• Emergency physicians must be the experts in electrocardiography!

References/Suggestions for Further Reading

Now available:
ECGs for the Emergency Physician Volume 1. Authors: Amal Mattu, William Brady.
Blackwell Publishing, 2003. A collection of 200 high-quality ECGs with diagnoses and advanced
teaching points. The first 100 ECGs focus on the intermediate level, and the second 100 ECGs
focus on the advanced level emergency practitioner.
Available through the ACEP bookstore, medical bookstores, Amazon.com, or similar sites.

ECGs for the Emergency Physician Volume 2. Authors: Amal Mattu, William Brady.
Blackwell Publishing, 2008. A collection of 200 additional high-quality ECGs with diagnoses
and advanced teaching points. Serves as a complement to Volume 2 with an added focus on
dysrhythmias, misdiagnoses, and advanced topics.
Available through the ACEP bookstore, medical bookstores, Amazon.com, or similar sites.

Electrocardiography in Emergency Medicine. Editors: Amal Mattu, Jeff Tabas, Bob Barish.
ACEP Publishing 2007. A textbook of electrocardiography covering basic and advanced topics,
highly illustrated. Available through the ACEP bookstore: https://secure2.acep.org/BookStore/c-
16-cardiology.aspx

Questions or comments? Please contact me:

Amal Mattu, MD
amalmattu@comcast.net

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Amal Mattu, MD