Medical - Cardiology 🫀 ECG discussion
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ECG discussion

Intermediate

Hello everyone,

I would like to share one of EKG’s that I thought it would have a great learning points especially with the feedback from our beloved teachers in the group.

I have already discussed the EKG with Dr @Mansour Khaddr who felt it would be better to post the case without a clinical scenario to see if we can pick up any findings outside the clinical context. The scenario will follow but I can give one liner ( 68yr old with ESRD on HD, CAD with Stent).

your input would be much appreciated!

Choices:

A-Hyperkalemia

B-Early (hyperacute) phase of acute myocardial infarction

C-Benign early repolarization

D-Takotsubo cardiomyopathy

FYI: this was from a teaching session with one of the Cardiologist from MGH Boston and not a personal clinical experience..

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Replies (12)

    • Nice case! @Mohammed Elagouri and @Mansour Khaddr ...

      I saw a similar case last Winter!...

      It is unfair to give the EKG without history, you need to give people some history 😄.

      I won't chime in anymore and won't steal its thunder, but let me give a small clue to make people more curious about it 😄 - the clue is "cold, snow, raining W....!)

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      • thank you Dr Fathi

        that’s a nice and clever clue😀

        Here is the scenario:

        A patient with a history of end-stage renal disease on intermittent hemodialysis and coronary artery disease s/p multiple prior stents presents with new chest pain and shortness of breath. He last underwent hemodialysis 3 days ago. A 12-lead EKG is obtained. What is the diagnosis?

      • Since pt is a known case of ESRD and IHD w/ h/o CP the main DDx are : Ischemia and hyperkalemia both need to be excluded.

        The interesting features in this EKG are : Upsloping STD + symmetrical T wave in precordial leads which lead us to Dr. @Fathi Idris clue (De winter syndrome = LAD occlusion)

        • 2

        • Excellent, anything else can be appreciated on this EKG?

        • High k

          • 2

          • Dr Khaled, k was 4.9..

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          • @Fathi Idris @Yousef Darrat

            Based solely on the EKG findings, could we tell if it is hyperkalemia vs ACS.

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            • Finding in this EKG:

              1-hyperacute T wave>> symmetrical (symmetrical can be high k or MI) symmetrical T>> mostly pathological (high k or MI) and non symmetrical argue against pathology.

              2-Dewinter sign as on v4,5.?v6. >> LAD disease

              3-short QTc>> ischemia>> hypoxia>> shutdown of Na-k ATPase>> building up of intracellular Na>> exchange of intracellular Na with extracellular Ca++>> high inteacellular Ca++>> short Qtc.

              short Qtc makes ischemia more likely which is the main reason why I felt I should post this EKG for discussion..

              What do you think Dr Fathi?

              • Ischemic effect is identical to what digoxin do on the myocardium.

                • I don't think based on this EKG alone you can be 100% sure of any of the above choices. Practically, the ischemic effects on QT interval can be unpredictable and are not enough to pin the diagnosis as there other variables that can affect it, and it may shrink or expand relative to baseline and yet still within normal limits. Same thing for the peaked T waves in hyperkalemia, as it is hard to have a very sold quantification on how tall, although in general tall T waves with narrow base are more suspicious of hyperkalemia, and a wider base (like in this case) point more towards ischemia, although I have seen exceptions. In these cases, it is so crucial to have an old EKG and correlate to a clinical setting.

                  In this case, the findings of Cardiac cath lab serial EKGs (with or without hyperkalemia Rx) will be the real confirmatory test.

                  I will share in this forum a classical DeWinter tracing that we have a few months ago at one point.

                  Great tracings Mohammed, you need to let us know what is the final verdict!

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                  • D

                    Hyperkalemia

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                    • Thank you Dr Fathi for the great explanation. The final Dx was mid-LAD occlusion.

                      this is the explanation from the source:-

                      Take-Home Points 

                      • T wave symmetry: most important parameter for distinguishing between abnormal and normal T waves (not T wave amplitude)Normal/non-pathologic T waves → asymmetric(upstroke ≠ downstroke)
                      • Abnormal/pathologic (“hyperacute”) → symmetric(upstroke = downstroke)
                      • Causes of symmetric (abnormal) T waves (whether tall or not): hyperkalemia, early phase of acute myocardial infarction (MI)
                      • EKG findings in early phase of acute MI:
                      • 1) Hyperacute T waves
                      • Cause: Ischemic damage to myocardium leads to malfunction of the Na+/K+ ATPase → Na+ remains in the cell, K+remains outside the cell → causes local extracellular hyperkalemia, causing peaked T waves
                      • 2) Short ST segment
                      • Cause: increased intracellular Na+ leads to reversal of the Na+/Ca2+ exchanger →pumps out Na+, pumps in Ca2+ → causes intracellular hypercalcemia, causing short ST segment
                      • 3) deWinter’s sign: upsloping ST depressions plus hyperacute T waves in the precordial leadsSpecific for early phase of acute MI due to LAD occlusion
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