(+)Amal Mattu, MD, FACEP

Associate ProIessor; Program Director.

Emergency Medicine Residency.
University oI Maryland School oI
Medicine. Baltimore. Maryland




Unrecognized Killers
in Emergency Cardiology

Sudden death can be prevented iI predisposing conditions are
detected. The speaker will discuss diseases that lead to
unexpected malignant dysrhythmias. including Brugada
syndrome. prolonged QT. and hypertrophic cardiomyopathy.
Diagnostic Ieatures on ECG. the recognition oI which may
prevent sudden death will also be discussed.
x Discuss ECG Iindings that may identiIy two genetic
conditions responsible Ior sudden death in otherwise
healthy patients.
x Discuss subtle ECG Iindings associated with electrolyte
abnormalities that predispose to malignant dysrhythmias.









TU-77
Tuesday. October 28. 2008
8:00 AM - 8:50 AM
McCormick Place - Lakeside Building




()No signiIicant Iinancial relationships to disclose


Unrecognized Killers
in
Emergency
Electrocardiography







Amal Mattu, MD, FACEP
Director, Emergency Medicine Residency Program
Associate Professor, Department of Emergency Medicine
University of Maryland School of Medicine
Baltimore, Maryland







OBJECTIVES

At the conclusion of this presentation, each participant should be able to. . .

1. Discuss electrocardiographic findings which may identify two genetic
conditions that are responsible for sudden death in otherwise healthy patients.
2. Discuss subtle electrocardiographic findings associated with electrolyte
abnormalities which predispose to malignant dysrhythmias.
Unrecognized Killers in Emergency Electrocardiography
Amal Mattu, MD
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Case 1, ECG (54 yo. woman with syncope)







Case 1, Rhythm strip














Unrecognized Killers in Emergency Electrocardiography
Amal Mattu, MD
3

Case 2, ECG (30 yo. man with near-syncope and palpitations)








Case 2, Rhythm strip











Unrecognized Killers in Emergency Electrocardiography
Amal Mattu, MD
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Case 3, ECG (40 yo. woman presenting after seizure)





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







Unrecognized Killers in Emergency Electrocardiography
Amal Mattu, MD
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Stop!

Please do not look at
the answers to the
preceding cases yet!






Unrecognized Killers in Emergency Electrocardiography
Amal Mattu, MD
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I. Brugada Syndrome

x More common cause of sudden death than previously recognized
x May be responsible for up to 20% of sudden deaths in individuals without
structural heart disease
x Responsible for 4-5% of all sudden deaths
x Incidence varies in different populations (some genetic factors involved)
x Most common in young males (< 50 yo.)
x First onset of symptoms approximately 40 yo.
x Mortality approximately 10% per year if not treated with an internal cardioverter-
defibrillator (ICD), regardless of whether or not antiarrhythmics are used

x Syndrome characterized by
x ECG abnormalities in leads V
1
V
3

x Polymorphic or monomorphic (less common) ventricular tachycardia
x Causes syncope if self-terminating
x Causes sudden death if persists and not terminated by treatment
x Structurally normal heart
x Familial occurrence in approximately half of patients

x ECG findings in leads V
1
V
3

x Right bundle branch block (RBBB) or incomplete RBBB pattern
x ST-segment elevation 2 types
x coved-type (most common)
x saddle-type
x ECG findings can vary with time depending on the autonomic balance,
administration of antiarrhythmic and other drugs affecting channel function, body
temperature, and other unknown factors

x Definitive diagnosis can be made with electrophysiologic testing
x Challenge with an intravenous class I medication (e.g. ajmaline, procainamide,
flecainide)
x Will induce increased ST-segment elevation and coving
x Programmed electrical stimulation of the heart
x Can induce ventricular tachycardia

x Treatment
x Placement of an ICD is the only effective treatment
x Antiarrhythmic drugs (including beta blockers, amiodarone, etc.) ineffective


II. Hypertrophic Cardiomyopathy (AKA IHSS, ASH, HOCM, etc.)

Unrecognized Killers in Emergency Electrocardiography
Amal Mattu, MD
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x Prevalence 0.02% 0.2% of the general population
x Genetic factors involved
x Hypertrophied but nondilated left ventricle
x Thickening is usually asymetric, involving the septum to a greater extent than the
free ventricular wall
x Cardiomegaly usually not present on chest x-ray
x Mortality 3.5% per year
x Diagnosis often made only when the patient experiences sudden death
x Usually occurs during exertion
x Average age at diagnosis is 30 40 yo.
x Patients may also experience syncope, angina, palpitations, dyspnea (often associated
with exertion)

x ECG findings
x Normal in 7% 15%
x Typical abnormalities
x Deep narrow Q-waves in the inferior and/or lateral leads I, aVL, V
5-6

(simulates MI, but Q-waves are too narrow for MI)
x Very specific for this condition
x Q-waves in lateral leads are more common than inferior leads, very
commonly misdiagnosed as lateral MI
x Left atrial enlargement
x High left ventricular voltage/left ventricular hypertrophy
x Other less common abnormalities
x Tall R-wave in lead V
1
(simulates posterior MI)
x Deep narrow Q-waves in the inferior leads (simulates inferior MI)
x Dont rely on your cardiologists to make the Dx on ECG!

x Clinical diagnosis
x Systolic murmur at apex or LLSB
x Murmur increases with valsalva, standing
x Murmur decreases with trendelenburg position, isometric exercise, squatting
x Definitive diagnosis doppler echocardiography

x Treatment
x Beta blockers, calcium channel blockers to improve LV filling and diastolic
function
x Amiodarone if ventricular dysrhythmias present


III. Prolonged QT-Interval

x Prolonged QT-interval predisposes to torsades de pointes
x One of the key cant miss diagnoses associated with syncope
Unrecognized Killers in Emergency Electrocardiography
Amal Mattu, MD
8
x Perhaps a more common cause of syncope and sudden death than previously
recognized?

x Causes of QT-prolongation
x Electrolyte abnormalities (hypokalemia, hypomagnesemia, hypocalcemia)
x Sodium channel blocking medications (many!)
x Includes Type IA medications, anticholinergics, cocaine, many antipsychotics,
some antibiotics
x Acute myocardial ischemia (usually associated with inverted T-waves)
x CNS lesions, e.g. intracerebral hemorrhage (often associated with giant inverted
T-waves)
x Hypothermia
x Congenital

x How long is too long?
x QT-interval will vary based on patients heart rate
x Measure QT from beginning of the QRS complex to the end of the T-wave, and
average over 3-5 beats
x Corrected QT-interval (Bazett formula): QTc = QT/o(RR)
x QTc is considered prolonged when > 450 msec in men and > 460 msec in women
and children
x Major risk occurs in patients with QTc > 500 msec

x Treatment
x Search for and correct underlying cause (e.g. correct electrolyte abnormalities,
discontinue responsible medications, etc.)
x Congenital or idiopathic causes: beta-blocking medications attenuate adrenergic-
mediated trigger mechanisms
x Treatment of torsades de pointes: cardioversion/defibrillation, magnesium if
relatively stable (e.g. intermittent torsades): 2 grams IV over 2-3 minutes
followed by infusion
x Overdrive pacing? Isoproterenol? Atropine? These are listed as possible
treatments in acquired (not for congenital) cases, but rarely needed
x Post-conversion treatment with magnesium, not lidocaine/amiodarone/
procainamide! (unlike other forms of ventricular tachycardia); for congenital
cases, add beta-blocking medications


IV. Pericardial Effusion

x Large pericardial effusions are classically associated with
x Electrical alternans (usually involves QRS complex, but may involve the P-wave
and/or T-wave also)
x Present in < 30%
Unrecognized Killers in Emergency Electrocardiography
Amal Mattu, MD
9
x Tachycardia
x May be blunted if the patient is taking cardiac medications
x Low voltage
x Defined as QRS amplitude in leads I + II + III < 15 mm OR QRS amplitude in
leads V
1
+ V
2
+ V
3
< 30 mm
x Differential diagnosis also includes obesity, COPD, large pleural effusions,
severe hypothyroidism, end-stage cardiomyopathies, infiltrative diseases (e.g.
sarcoid, amyloid, scleroderma), massive MI
x New low voltage (compared to a recent ECG): think pericardial effusion or
pleural effusion
x Chest pain/pressure and dyspnea are most common
x Hypotension + JVD often when tamponade is present
x CXR usually demonstrates cardiomegaly (very sensitive but non-specific)
x Always consider the diagnosis in a patient with cardiopulmonary symptoms that
has tachycardia + low voltage!


V. Summary

x Young patients with syncope or other cardiac complaints need ECG evaluation for:
x Brugada syndrome
x Refer for urgent electrophysiologic testing and ICD placement
x Hypertrophic cardiomyopathy
x Refer for urgent doppler echocardiography for definitive diagnosis
x Prolonged QT-interval
x Suspect torsades de pointes as cause of syncope
x Treatment of torsades: electricity vs. magnesium
x Post-conversion treatment: if acquired, treat with magnesium alone; if
congenital, add beta-blocking medications
x Avoid Type I antidysrhythmics, including lidocaine, amiodarone, and
procainamide!
x Pericardial effusion should be suspected in any patient with LV + tachycardia
x Especially if LV is new
x Recognition of these subtle abnormalities will make the difference between life and
death!
x Dont rely on your cardiology consultants to make these diagnoses
x Emergency physicians must be the experts in electrocardiography!


VI. 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
Unrecognized Killers in Emergency Electrocardiography
Amal Mattu, MD
10
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


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Brugada P, Brugada J: Right bundle branch block, persistent ST segment elevation and sudden
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Brugada P, Brugada R, Brugada J: The Brugada syndrome. Curr Cardiol Rep 2000;2:507-14.

Chung EC: ECG Diagnosis and Self-Assessment CD-ROM. Blackwell Science, Inc., 1997.

Surawicz B, Knilans TK: Chous Electrocardiography in Clinical Practice, 5
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PA, W.B. Saunders Company, 2001.

Gowda RM, Khan IA, Wilbur SL, et al. Torsade de pointes: the clinical considerations. Int J
Cardiol 2004;96:1-6.

Homme JH, White RD, Ackerman MJ: Management of ventricular fibrillation or unstable
ventricular tachycardia in patients with congenital long-QT syndrome: a suggested modification
to ACLS guidelines. Resuscitation 2003;59:111-5.

Mancuso EM, Brady WJ, Harrigan RA, et al. Electrocardiographic manifestations: long QT
syndrome. J Emerg Med 2004;27:385-93.

Maron BJ: Hypertrophic cardiomyopathy: A systematic review. JAMA 2002;287:1308-20.

Marriott HJL: Emergency Electrocardiography. Naples, FL, Trinity Press, 1997, pp 28-36.

Mattu A, Rogers RL, Kim H, et al: The Brugada syndrome. Am J Emerg Med 2003;21:146-151.

Priori SG, Schwartz PJ, Napolitano C, et al: Risk stratification in the long-QT syndrome. N Engl
J Med 2003;348:1866-74.

Unrecognized Killers in Emergency Electrocardiography
Amal Mattu, MD
11
Spirito P, Chiarella F, Carratino L, Berisso MZ, Bellotti P, Vecchio C: Clinical course and
prognosis of hypertrophic cardiomyopathy in an outpatient population. N Engl J Med
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Questions or comments? Please contact me:
Amal Mattu, MD, FAAEM, FACEP
amattu@smail.umaryland.edu