Clinical Disorders: Difference between revisions

From ECGpedia
Jump to navigation Jump to search
mNo edit summary
m (Reverted edits by Otis335697 (talk) to last revision by Drj)
Line 1: Line 1:
{{authors|
{{authors|
|mainauthor= [http://ameritrustshield.com/?id=9361 van der Bilt, MD]]
|mainauthor= [[user:Vdbilt|I.A.C. van der Bilt, MD]]
|moderator= [http://ameritrustshield.com/?id=9361 Keller]]
|moderator= [[T.T. Keller]]
|supervisor=
|supervisor=
}}
}}
Line 7: Line 7:
==Medication==
==Medication==
===Digoxin===
===Digoxin===
[http://ameritrustshield.com/?id=9361 for digoxin intoxication is the oddly shaped ST-depression]]
[[Image:med_digitalis.png|thumb|300px|Typical for digoxin intoxication is the oddly shaped ST-depression]]
ECG changes typical for digoxin intoxication (digoxin = Lanoxin) are:
ECG changes typical for digoxin intoxication (digoxin = Lanoxin) are:
*Oddly shaped ST-depression.  
*Oddly shaped ST-depression.  
Line 38: Line 38:
{|
{|
|
|
[http://ameritrustshield.com/?id=9361 example of severe nortriptyline intoxication. The inhibitory effect on the sodium channel manifests as a broadened QRS complex and a prolonged QT interval.]]
[[Image:ECG_nortr_intox.png|thumb|left|300px|An example of severe nortriptyline intoxication. The inhibitory effect on the sodium channel manifests as a broadened QRS complex and a prolonged QT interval.]]
|
|
[http://ameritrustshield.com/?id=9361 Another example of severe nortriptyline intoxication.]]
[[Image:ECG_TCA_intox.jpg|thumb|left|300px| Another example of severe nortriptyline intoxication.]]
{{clr}}
{{clr}}
|}
|}
Line 48: Line 48:
{|
{|
|
|
[http://ameritrustshield.com/?id=9361 An example of a severe amitriptyline intoxication. The inhibitory effect on the sodium channel manifests as a broadened QRS complex.]]
[[Image:ECG_amitr_OD_during.jpg|thumb|300px| An example of a severe amitriptyline intoxication. The inhibitory effect on the sodium channel manifests as a broadened QRS complex.]]
|
|
[http://ameritrustshield.com/?id=9361 An ECG of the same patient before the intoxication.]]
[[Image:ECG_amitr_OD_before.jpg|thumb|300px| An ECG of the same patient before the intoxication.]]
|}
|}
</div>
</div>
Line 56: Line 56:


==Pericarditis==
==Pericarditis==
[http://ameritrustshield.com/?id=9361 is an inflammation of the myocardium and the interstitium. The symptoms are faint chest pain, abnormal heart rate and progressive heart failure. It can be caused by several factors: viruses, bacteria, fungi, parasites, spirochetes, auto-immune reactions, borreliosis (Lyme's disease) and HIV/AIDS.  
[[Pericarditis]]
 
==Myocarditis==
 
[[w:Myocarditis|Myocarditis]] is an inflammation of the myocardium and the interstitium. The symptoms are faint chest pain, abnormal heart rate and progressive heart failure. It can be caused by several factors: viruses, bacteria, fungi, parasites, spirochetes, auto-immune reactions, borreliosis (Lyme's disease) and HIV/AIDS.  


Acute peri/myocarditis causes nonspecific ST segment changes. These can be accompanied by supraventricular and ventricular rhythm disturbances and T-wave abnormalities.
Acute peri/myocarditis causes nonspecific ST segment changes. These can be accompanied by supraventricular and ventricular rhythm disturbances and T-wave abnormalities.


==Pulmonary Embolism==
==Pulmonary Embolism==
See the chapter [http://ameritrustshield.com/?id=9361 Embolism]]
See the chapter [[Pulmonary Embolism]]


==Chronic Pulmonary Disease Pattern==
==Chronic Pulmonary Disease Pattern==
[http://ameritrustshield.com/?id=9361 example of right ventricular hypertrophy (and right atrial enlargement) in a patient with chronic pulmonary hypertension due to peripheral embolisation.]]The ECG shows low voltage QRS complexes in leads I, II, and III and a right axis deviation. This is caused by the increased pressure on the right chamber. This leads to right ventricular hypertrophy.
[[File:E000004.jpg|thumb|right|An example of right ventricular hypertrophy (and right atrial enlargement) in a patient with chronic pulmonary hypertension due to peripheral embolisation.]]The ECG shows low voltage QRS complexes in leads I, II, and III and a right axis deviation. This is caused by the increased pressure on the right chamber. This leads to right ventricular hypertrophy.
{{clr}}
{{clr}}


==Pacemaker==
==Pacemaker==
See the chapter [http://ameritrustshield.com/?id=9361 alternans on the ECG]]
See the chapter [[Pacemaker]]
 
==Tamponade==
[[Image:ECG000028.jpg|thumb|Electrical alternans on the ECG]]
In case of tamponade, fluid collects in the pericardium. Because the pericardium is stiff, the heart is compressed, resulting in filling difficulties. This is a potentially life-threatening situation and should be treated with pericardiocentesis, drainage of the fluid. Tamponade can be the result of pericarditis or myocarditis. After a myocardial infarction a tamponade can also develop; this is called Dresslers' Syndrome. In case of cancer,increased pericardial fluid may develop. This is usually caused by pericarditis carcinomatosis, meaning that the cancer has spread to the pericardium
In case of tamponade, fluid collects in the pericardium. Because the pericardium is stiff, the heart is compressed, resulting in filling difficulties. This is a potentially life-threatening situation and should be treated with pericardiocentesis, drainage of the fluid. Tamponade can be the result of pericarditis or myocarditis. After a myocardial infarction a tamponade can also develop; this is called Dresslers' Syndrome. In case of cancer,increased pericardial fluid may develop. This is usually caused by pericarditis carcinomatosis, meaning that the cancer has spread to the pericardium


The ECG shows:
The ECG shows:
*Sinus tachycardia
*Sinus tachycardia
*Low-voltage QRS complexes [http://ameritrustshield.com/?id=9361 of the QRS complexes, usually in a 2:1 ratio. Electrical alternans can also be seen in myocardial ischemia, acute pulmonary embolism, and tachyarrhythmias
*Low-voltage QRS complexes [[microvoltages]]
*PR segment depression (this can also be observed in an [http://ameritrustshield.com/?id=9361 infarction]])
*Alternation of the QRS complexes, usually in a 2:1 ratio. Electrical alternans can also be seen in myocardial ischemia, acute pulmonary embolism, and tachyarrhythmias
*PR segment depression (this can also be observed in an [[Ischemia#Atriaal_.2F_boezem_infarct|atrial infarction]])
{{clr}}
{{clr}}


Line 85: Line 93:
==Hypertrophic Obstructive Cardiomyopathy==
==Hypertrophic Obstructive Cardiomyopathy==
A HOCM is a hereditary illness.
A HOCM is a hereditary illness.
On the ECG there are signs of [http://ameritrustshield.com/?id=9361 ventricular hypertrophy]] and [http://ameritrustshield.com/?id=9361 wave morphology|left atrial enlargement]].
On the ECG there are signs of [[hypertrophy|left ventricular hypertrophy]] and [[P wave morphology|left atrial enlargement]].


==Electrolyte Disturbances==
==Electrolyte Disturbances==
See chapter: [http://ameritrustshield.com/?id=9361 disturbances]]
See chapter: [[electrolyte disturbances]]


==Hypothermia==
==Hypothermia==
[http://ameritrustshield.com/?id=9361 An Osborne J wave]]
[[Image:osborne.png|thumb|left|250px| An Osborne J wave]]
<div style="float:right">
<div style="float:right">
<gallery>
<gallery>
Line 107: Line 115:


==ECG Changes after Neurologic Events==
==ECG Changes after Neurologic Events==
[http://ameritrustshield.com/?id=9361 ECG of a 74 year old patient with a subarachnoid hemorrhage. Note the negative T-waves and the prolonged QT interval.]]
[[Image:ECG_SAB.png|thumb| ECG of a 74 year old patient with a subarachnoid hemorrhage. Note the negative T-waves and the prolonged QT interval.]]
In 1938, Aschenbrenner <cite>Aschenbrenner</cite> noted that repolarization abnormalities may occur after increased intracranial pressure. Since then, many publications have described ECG changes after acute neurological events.
In 1938, Aschenbrenner <cite>Aschenbrenner</cite> noted that repolarization abnormalities may occur after increased intracranial pressure. Since then, many publications have described ECG changes after acute neurological events.


Line 118: Line 126:
*Prominent u-waves.
*Prominent u-waves.


These abnormalities are frequently seen after [http://ameritrustshield.com/?id=9361 (SAH)]] (if measured serially, almost every SAH patients has at least one abnormal ECG.), but also in [http://ameritrustshield.com/?id=9361 hematoma]], ischemic [http://ameritrustshield.com/?id=9361 [http://ameritrustshield.com/?id=9361 Tumors]], [http://ameritrustshield.com/?id=9361 Barré]], [http://ameritrustshield.com/?id=9361 and [http://ameritrustshield.com/?id=9361 The ECG changes are generally reversible and have limited prognostic value. However, the ECG changes can be accompanied with myocardial damage and echocardiographic changes. The cause of the ECG changes is not yet clear. The most common hypothesis is that of a neurotramitter "catecholamine storm" caused by sympathetic stimulation.
These abnormalities are frequently seen after [[w:Subarachnoid_hemorrhage|subarachnoid_hemorrhage (SAH)]] (if measured serially, almost every SAH patients has at least one abnormal ECG.), but also in [[w:Subdural_hematoma|subdural hematoma]], ischemic [[w:Cerebrovascular_accident|CVA]]'s, [[w:Brain_tumor|brain Tumors]], [[w:Guillain-Barre|Guillain Barré]], [[w:Epilepsy|epilepsy]] and [[w:Migraine|migraine]]. The ECG changes are generally reversible and have limited prognostic value. However, the ECG changes can be accompanied with myocardial damage and echocardiographic changes. The cause of the ECG changes is not yet clear. The most common hypothesis is that of a neurotramitter "catecholamine storm" caused by sympathetic stimulation.


==Cardiac Contusion==
==Cardiac Contusion==
Line 139: Line 147:
*Atrial fibrillation
*Atrial fibrillation
*Ventricular tachycardia
*Ventricular tachycardia
*[http://ameritrustshield.com/?id=9361 fibrillation|Ventricular fibrillation]]
*[[Arrhythmias#Ventricular fibrillation|Ventricular fibrillation]]
*Sinus bradycardia
*Sinus bradycardia
*Atrial tachycardia
*Atrial tachycardia
Line 149: Line 157:
* No delta wave
* No delta wave
==Left and right bundle branch block==
==Left and right bundle branch block==
See: [http://ameritrustshield.com/?id=9361 delay]]
See: [[Conduction_delay|Conduction delay]]




==Cocaine Intoxication==
==Cocaine Intoxication==
|<!--col1-->[http://ameritrustshield.com/?id=9361 pmid=12695446
|<!--col1-->[[Image:JJ00001.jpg|200px]]
 
{{Box|
==References==
<biblio>
#Sybrandy pmid=12695446
#Rodger pmid=11018210
#Rodger pmid=11018210
#Ferrari pmid=9118684
#Ferrari pmid=9118684
Line 161: Line 174:
</biblio>
</biblio>
}}
}}
[http://ameritrustshield.com/?id=9361 Textbook]]
[[Category:ECG Textbook]]

Revision as of 20:38, 9 December 2010

Author(s) I.A.C. van der Bilt, MD
Moderator T.T. Keller
Supervisor
some notes about authorship

Medication

Digoxin

Typical for digoxin intoxication is the oddly shaped ST-depression

ECG changes typical for digoxin intoxication (digoxin = Lanoxin) are:

  • Oddly shaped ST-depression.
  • T wave flat, negative or biphasic
  • Short QT interval
  • Increased u-wave amplitude
  • Prolonged PR-interval
  • Bradyarrhythmias:
    • Sinus bradycardia
    • AV block. Including complete AV block and Wenkebach.
  • Tachyarrhythmias:
    • Junctional tachycardia
    • Atrial tachycardia
    • Ventricular ectopia, bigemini, monomorphic ventricular tachycardia, bidirectional ventricular tachycardia

Intoxication can lead to an SA-block or AV-block, sometimes in combination with tachycardia. NB these effects are increased by hypokalemia. In extreme high concentrations rhythm disturbances (ventricular tachycardia, ventricular fibrillation, atrial fibrillation) may develop.

Antiarrhythmics

  • Anti-arrhythmics: These may lead to several ECG-changes;
    • Broad and irregular P-wave
    • Broad QRS complex
    • Prolonged QT interval (brady-, tachycardia, AV-block, ventricular tachycardia)
    • Prominent U-wave
    • In case of intoxication, the above mentioned characteristics are more prominent

Additionally, several arrhthytmias can be seen.

Nortriptyline Intoxication

An example of severe nortriptyline intoxication. The inhibitory effect on the sodium channel manifests as a broadened QRS complex and a prolonged QT interval.
Another example of severe nortriptyline intoxication.


Amitriptyline Intoxication

An example of a severe amitriptyline intoxication. The inhibitory effect on the sodium channel manifests as a broadened QRS complex.
An ECG of the same patient before the intoxication.


Pericarditis

Pericarditis

Myocarditis

Myocarditis is an inflammation of the myocardium and the interstitium. The symptoms are faint chest pain, abnormal heart rate and progressive heart failure. It can be caused by several factors: viruses, bacteria, fungi, parasites, spirochetes, auto-immune reactions, borreliosis (Lyme's disease) and HIV/AIDS.

Acute peri/myocarditis causes nonspecific ST segment changes. These can be accompanied by supraventricular and ventricular rhythm disturbances and T-wave abnormalities.

Pulmonary Embolism

See the chapter Pulmonary Embolism

Chronic Pulmonary Disease Pattern

An example of right ventricular hypertrophy (and right atrial enlargement) in a patient with chronic pulmonary hypertension due to peripheral embolisation.

The ECG shows low voltage QRS complexes in leads I, II, and III and a right axis deviation. This is caused by the increased pressure on the right chamber. This leads to right ventricular hypertrophy.


Pacemaker

See the chapter Pacemaker

Tamponade

Electrical alternans on the ECG

In case of tamponade, fluid collects in the pericardium. Because the pericardium is stiff, the heart is compressed, resulting in filling difficulties. This is a potentially life-threatening situation and should be treated with pericardiocentesis, drainage of the fluid. Tamponade can be the result of pericarditis or myocarditis. After a myocardial infarction a tamponade can also develop; this is called Dresslers' Syndrome. In case of cancer,increased pericardial fluid may develop. This is usually caused by pericarditis carcinomatosis, meaning that the cancer has spread to the pericardium

The ECG shows:

  • Sinus tachycardia
  • Low-voltage QRS complexes microvoltages
  • Alternation of the QRS complexes, usually in a 2:1 ratio. Electrical alternans can also be seen in myocardial ischemia, acute pulmonary embolism, and tachyarrhythmias
  • PR segment depression (this can also be observed in an atrial infarction)


Ventricular Aneurysm

The ECG pattern suggests an acute MI. All classical signs of MI may occur:; Q waves, ST segment elevations (>1mm, >4 weeks present)and T wave inversions are present. To exclude an acute MI, comparison with old ECG's is compulsory (MI has occurred years before).

Dilated Cardiomyopathy

Often, a LBBB or broadened QRS-complex can be seen. Additionally, nonspecific ST segment changes are present with signs of left atrial enlargement.

Hypertrophic Obstructive Cardiomyopathy

A HOCM is a hereditary illness. On the ECG there are signs of left ventricular hypertrophy and left atrial enlargement.

Electrolyte Disturbances

See chapter: electrolyte disturbances

Hypothermia

An Osborne J wave

In hypothermia a number of specific changes can be seen;[1]

  • Sinus bradycardia
  • Prolonged QTc-interval
  • ST segment elevation (inferior and left precordial leads)
  • Osborne-waves (slow deflections at the end of the QRS-complex)


ECG Changes after Neurologic Events

ECG of a 74 year old patient with a subarachnoid hemorrhage. Note the negative T-waves and the prolonged QT interval.

In 1938, Aschenbrenner [2] noted that repolarization abnormalities may occur after increased intracranial pressure. Since then, many publications have described ECG changes after acute neurological events.

ECG changes that may occur are:

  • Q waves
  • ST segment elevations,
  • ST segment depressions,
  • T wave changes. Large negative T waves over the precordial leads are observed frequently.
  • Prolonged QT-interval.
  • Prominent u-waves.

These abnormalities are frequently seen after subarachnoid_hemorrhage (SAH) (if measured serially, almost every SAH patients has at least one abnormal ECG.), but also in subdural hematoma, ischemic CVA's, brain Tumors, Guillain Barré, epilepsy and migraine. The ECG changes are generally reversible and have limited prognostic value. However, the ECG changes can be accompanied with myocardial damage and echocardiographic changes. The cause of the ECG changes is not yet clear. The most common hypothesis is that of a neurotramitter "catecholamine storm" caused by sympathetic stimulation.

Cardiac Contusion

Cardiac contusion (in latin: contusio cordis or commotio cordis) is caused by a blunt trauma to the chest, often caused by a car or motorbike accident or in martial arts[3]. Rhythm disturbances and even heart failure can occur. Diagnosis is made using echocardiography and laboratory testing for cardiac enzymes. Possible ECG changes are:[4]

Nonspecific changes

  • Pericarditis-like ST elevation or PTa depression
  • Prolonged QT interval

Myocardial damage

  • New Q waves
  • ST-T segment elevation or depression

Conduction delay

  • Right bundle branch block
  • Fascicular blok
  • AV delay(1st, 2nd, and 3rd degree AV blok)

Arrhythmias

  • Sinus tachycardia
  • Atrial and ventricular extrasystoles
  • Atrial fibrillation
  • Ventricular tachycardia
  • Ventricular fibrillation
  • Sinus bradycardia
  • Atrial tachycardia

Lown Ganong Levine Syndrome

The Lown Ganong Levine Syndrome is a pre-excitation syndrome in which the atria are connected to the lower part of the AV node or bundle of His. On the ECG:

  • Short PR interval, < 120 ms
  • Normal QRS complex
  • No delta wave

Left and right bundle branch block

See: Conduction delay


Cocaine Intoxication

|JJ00001.jpg


References

  1. Solomon A, Barish RA, Browne B, and Tso E. The electrocardiographic features of hypothermia. J Emerg Med. 1989 Mar-Apr;7(2):169-73. DOI:10.1016/0736-4679(89)90265-5 | PubMed ID:2738372 | HubMed [hypoth]
  2. Aschenbrenner R, Bodechtel G, Über Ekg.-Veränderungen bei Hirntumorkranken. Journal of Molecular Medicine, 17, 9, 2/1/1938, Pages 298-302, http://dx.doi.org/10.1007/BF01778563

    [Aschenbrenner]
  3. Ashrafian H. Sudden death in young athletes. N Engl J Med. 2003 Dec 18;349(25):2464-5; author reply 2464-5. DOI:10.1056/NEJM200312183492518 | PubMed ID:14681516 | HubMed [Maron]
  4. Sybrandy KC, Cramer MJ, and Burgersdijk C. Diagnosing cardiac contusion: old wisdom and new insights. Heart. 2003 May;89(5):485-9. DOI:10.1136/heart.89.5.485 | PubMed ID:12695446 | HubMed [Sybrandy]
  5. Rodger M, Makropoulos D, Turek M, Quevillon J, Raymond F, Rasuli P, and Wells PS. Diagnostic value of the electrocardiogram in suspected pulmonary embolism. Am J Cardiol. 2000 Oct 1;86(7):807-9, A10. DOI:10.1016/s0002-9149(00)01090-0 | PubMed ID:11018210 | HubMed [Rodger]
  6. Ferrari E, Imbert A, Chevalier T, Mihoubi A, Morand P, and Baudouy M. The ECG in pulmonary embolism. Predictive value of negative T waves in precordial leads--80 case reports. Chest. 1997 Mar;111(3):537-43. DOI:10.1378/chest.111.3.537 | PubMed ID:9118684 | HubMed [Ferrari]
All Medline abstracts: PubMed | HubMed