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{{authors|
|mainauthor= [[user:Vdbilt|I.A.C. van der Bilt, MD]]
|moderator= [[T.T. Keller]]
|supervisor=
}}
==Medication==
==Medication==
===Digitalis===
===Digoxin===
[[Image:med_digitalis.png|thumb|Typical for digitalisintoxication are the komvormige ST-depressie]]
[[Image:med_digitalis.png|thumb|300px|Typical for digoxin intoxication is the oddly shaped ST-depression]]
Afwijkingen op het ECG die passen bij digitalisintoxicatie (digitalis = Lanoxin) zijn:
ECG changes typical for digoxin '''use''' (digoxin = Lanoxin) are:
*komvormige ST-depressie.
*Oddly shaped ST-depression with 'scooped out' appearance of the ST segment (see figure)
*T-top vlak, negatief of bifasisch
*Flat, negative or biphasic T wave
*QT is verkort
*Short QT interval
*Verhoogde u-golf amplitude
*Increased u-wave amplitude
*Verlengt PR- interval
*Prolonged PR-interval
*Brady-aritmiën:
*Sinus bradycardia
**Sinusbradycardie
ECG changes typical for digoxin '''intoxication''' are:
**AV blok. Inclusief compleet AV blok en Wenkebach.
*Bradyarrhythmias:
*Tachyaritmiën:
**AV block. Including complete AV block and Wenkebach.
**Junctionele tachycardie
*Tachyarrhythmias:
**Boezemtachycardie
**Junctional tachycardia
**Ventriculaire ectopie, bigemini, monomorfe ventriculaire tachycardie, bidirectionele ventriculaire tachycardie
**Atrial tachycardia
**Ventricular ectopia, bigemini, monomorphic ventricular tachycardia, bidirectional ventricular tachycardia


Intoxicatie kan leiden tot een SA-blok of AV-blok eventueel i.c.m. een tachycardie. '''NB''' de effecten hiervan worden versterkt door hypokaliëmie. In extreme hoge concentraties kunnen ritmestoornissen (''ventriculaire tachycardie, ventrikelfibbrileren, atriumfibbrileren'') ontstaan. Als oorzaak wordt vaak het prikkelen van ectopische foci aangewezen.
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.
{{clr}}


===Anti-artimetica===
===Antiarrhythmics===
* '''anti-aritmica :''' Deze kunnen tot een scala aan ECG-veranderingen leiden;
* '''Anti-arrhythmics:''' These may lead to several ECG-changes;
**brede en onregelmatige P-top
**Broad and irregular P-wave
**verlenging en brede QRS-complex
**Broad QRS complex
**verlenging QT-interval (brady-, tachycardieën, AV-blok, ventriculair tachycardie)
**Prolonged QT interval (brady-, tachycardia, AV-block, ventricular tachycardia)
**ontstaan van U-golf
**Prominent U-wave
**bij intoxicatie is er een versterking van de bovengenoemde kenmerken--> ontstaat het effect van een glijbaan
**In case of intoxication, the above mentioned characteristics are more prominent


Daarnaast kunnen er als bijwerking ritmestoornissen optreden (pro-aritmische werking)
Additionally, several arrhthytmias can be seen.
===Beta blockers===
[[File:E000542.jpg|thumb|right|ECG of a patient with atenolol intoxication]]Beta blocker intoxication can result in bradycardia, hypotension, QRS widening and seizures. In a series of 260 patients with beta blocker intoxication, 41 (15%) developed cardiovascular morbidity and 4 (1.4%) died. Cardioactive coingestant (e.g. calcium channel blockers) was the only factor significantly associated with the development of cardiovascular morbidity. <cite>bb</cite>
{{clr}}


=== Nortriptyline intoxicatie ===
=== Nortriptyline Intoxication ===
[[Image:ECG_nortr_intox.png|thumb| Een voorbeeld van ernstige nortriptyline intoxicatie. Het natriumkanaal remmende effect uit zich in een verbreed QRS complex en een verlengde QT tijd.]]
<div align="center">
{|
|
[[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.]]
|
[[Image:ECG_TCA_intox.jpg|thumb|left|300px| Another example of severe nortriptyline intoxication.]]
{{clr}}
{{clr}}
 
|}
=== Amitriptyline intoxicatie ===
</div>
[[Image:ECG_amitr_OD_during.jpg|thumb| Een voorbeeld van ernstige amitriptyline intoxicatie. Het natriumkanaal remmende effect uit zich in een verbreed QRS complex.]]
=== Amitriptyline Intoxication ===
[[Image:ECG_amitr_OD_before.jpg|thumb| Een ECG van dezelfde patient vóór de intoxicatie.]]
<div align="center">
 
{|
|
[[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.]]
|
[[Image:ECG_amitr_OD_before.jpg|thumb|300px| An ECG of the same patient before the intoxication.]]
|}
</div>
{{clr}}
{{clr}}


==Pericarditis==
==Pericarditis==
[[Image:Stadia_pericarditis.png|thumb| Verschilende stadia van pericarditis]]
[[Pericarditis]]
[[w:Pericarditis|Pericarditis]] is een ontsteking van het hartzakje (pericard). Hierbij kan er ST elevatie in 'alle' afleidingen ontstaan. Het is dus belangrijk dit te onderscheiden van een myocard-infarct, waarbij de klachten meestal acuter zijn en de ST elevatie zich beperkt tot het infarctgebied.


Bij pericarditis heb je in pricipe vier stadia:
==Myocarditis==
*stadium I:   ST elevatie in bijna alle afleidingen. PTa depressie (depressie tussen het einde van de P top en het begin van het QRS complex)
[[File:E000535.jpg|thumb|A patient with myocarditis and pericarditis showing diffuse ST elevation]]
*stadium II:   pseudonormalisatie (transitie)
[[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.
*stadium III:  omgekeerde T-waves
*stadium IV:  normailsatie


Houd er rekening mee dat je bij het zoeken naar stadium I pericarditis, ST-elevatie hebt in alle afleidingen behalve in aVR, V1 en III.
Acute peri/myocarditis causes nonspecific ST segment changes. These can be accompanied by supraventricular and ventricular rhythm disturbances and T-wave abnormalities.
{{clr}}
{{clr}}


==Myocarditis==
==Pulmonary Embolism==
See the chapter [[Pulmonary Embolism]]


[[w:Myocarditis|Myocarditis]] is een ontsteking van het myocard en interstitium. De symptomen zijn vage borstpijn, abnormale hartslag en progressief hartfalen. Het kan allerlei oorzaken hebben: viraal, bacterieel, schimmel, parasiet, spirochaet, auto-immuun, borreliose (ziekte van Lyme) en AIDS.  
==Chronic Pulmonary Disease Pattern==
[[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}}


Acute pericarditis veroorzaakt aspecifieke ST veranderingen. Deze kunnen gepaard gaan met supraventriculaire als ventriculaire ritmestoornissen en T golf afwijkingen komen ook voor.
==Pacemaker==
See the chapter [[Pacemaker]]


==Longembolie==
==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


Bij een [[w:Pulmonary_embolism|longembolie]] zijn een aantal kenmerken te onderscheiden:<cite>Rodger</cite>
The ECG shows:
* Sinustachycardie
*Sinus tachycardia
* Rechtsbelasting, zich uitend in:
*Low-voltage QRS complexes [[microvoltages]]
**[[P_top_morfologie|Rechteratriumdilatatie]]
*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
**Hartasdraai naar rechts
*PR segment depression (this can also be observed in an [[Ischemia#Atriaal_.2F_boezem_infarct|atrial infarction]])
**[[bundeltakblok|Rechter bundeltakblok]]
{{clr}}
* Diepe S in I
* Q en negatieve T in III
* T top inversie anterior <cite>Ferrari</cite>


Overigens is een longembolie niet op een ECG te diagnostiseren, het kan alleen als hulpmiddel dienen.
==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).


==Longemfyseem==
==Dilated Cardiomyopathy==
Het ECG toont in de afleidingen I, II, III laag gevolteerde QRS-complexen. Tevens vindt men een rechter asdraaing (negatieve QRS-complex). Dit wordt veroorzaakt door de verhoogde weerstand waartegen de rechter kamer moet pompen. Dit leidt tot rechter kamerhypertrofie.
Often, a LBBB or broadened QRS-complex can be seen. Additionally, nonspecific ST segment changes are present with signs of left atrial enlargement.


==Pacemaker==
==Hypertrophic Obstructive Cardiomyopathy==
Zie het eigen hoofdstuk [[Pacemaker]]
A HOCM is a hereditary illness.
 
On the ECG there are signs of [[hypertrophy|left ventricular hypertrophy]] and [[P wave morphology|left atrial enlargement]].
==Tamponade==
Bij een tamponade bevindt er zich zoveel vocht in het hartzakje dat het hart samengedrukt wordt en niet meer goed kan pompen. Het ECG toont:
*Sinus tachycardia
*Laag-voltage QRS complexen, [[microvoltages]]
*Alternatie van de QRS complexen, veelal in een 2:1 ratio. Electrische alternans wordt ook gezien bij patienten met myocard ischemie, acute pulmonaire embolie, en tachyarrhythmien
*PR segment depressie (dit is ook te zien bij een [[Ischemie#Atriaal_.2F_boezem_infarct|atriaal infarct]])


==Ventriculair Aneurysma==
==Electrolyte Disturbances==
Het ECG patroon suggereert een acute MI. Alle klassieke tekenen van een MI; Q-golven, ST-elevaties (>1mm, >4 weken aanwezig)en T-golf inversies zijn aanwezig. Ter uitsluiting van een MI, is vergelijking met oude ECG's verreist (MI heeft jaren eerder plaatsgevonden).
See chapter: [[electrolyte disturbances]]


==Gedilateerde Cardiomyopathie==
==Hypothermia==
Vaak ziet men hierbij een LBTB of een verbreed QRS-complex. Tevens zijn hier ook aspecifieke ST veranderingen aanwezig. Daarnaast vindt men ook tekenen van linkerboezemdilatatie.
[[Image:osborne.png|thumb|left|250px| An Osborn J wave]]
[[Image:Osborn-wave.gif|thumb|left|250px|Osborn wave.  81-year-old black male with BP 80/62 and temperature 89.5 degrees F (31.94 C).]]
<div style="float:right">
<gallery>
Image:osborne_ecg.jpg|A 12 lead ECG of a patient with a body temperature of 32 degrees Celsius. Note the sinus bradycardia, the prolonged QT interval (QTc is not prolonged) and the Osborn J wave, most prominently in leads V2-V5
Image:JJ0001.jpg|An ECG of a patient with a body temperature of 28 degrees Celsius.
</gallery>
</div>
In hypothermia a number of specific changes can be seen;<cite>hypoth</cite>
* Sinus bradycardia
* Prolonged QTc-interval
* ST segment elevation (inferior and left precordial leads)
* Osborn-waves (slow deflections at the end of the QRS-complex)


==Hypertrofische Obstructieve Cardiomyopathie==
{{clr}}
HOCM is een erfelijke aandoening
Deze vertonen meestal tekenen van [[ventrikelhypertrofie|linkerkamerhypertrofie]] en [[P_top_morfologie|linkerboezemdilatatie]].


==Electrolytstoornissen==
==ECG Changes after Neurologic Events==
Zie het eigen hoofdstuk: [[electrolytstoornissen]]
[[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.


==Hypothermie==
ECG changes that may occur are:
Bij onderkoeling vindt men een aantal karakteristieke afwijkingen;
*Q waves
* sinubradycardie
*ST segment elevations,
* verlenging QTc-interval
*ST segment depressions,
* ST-elevatie (onderwand en links-precordiale afleidingen)
*T wave changes. Large negative T waves over the precordial leads are observed frequently.
* Osborne-golven (trage deflexies aan het einde van het QRS-complex)
*Prolonged QT-interval.
*Prominent u-waves.


[[Image:osborne.gif|thumb| een Osborne J golf]]
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.
{{clr}}


==ECG uitingen van cerebrale aandoeningen==
==Cardiac Contusion==
[[Image:ECG_SAB.png|thumb| ECG van een 74 jarige patiënte met een subarachnoïdale bloeding. Met name de negatieve T -toppen en de QT verlening vallen op.]]
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<cite>Maron</cite>. Rhythm disturbances and even heart failure can occur. Diagnosis is made using echocardiography and laboratory testing for cardiac enzymes.  
In 1938 publiceerde Aschenbrenner <cite>Aschenbrenner</cite> dat repolaristatiestoornissen kunnen optreden bij intracraniële drukverhoging. Sindsdien zijn er veel publicaties verschenen waarbij ECG afwijkingen zijn beschreven bij aandoeningen van het centrale zenuwstelsel.
Possible ECG changes are:<cite>Sybrandy</cite>


De ECG afwijkingen die zijn beschreven zijn:
'''Nonspecific changes'''
*ST-elevaties,
*Pericarditis-like ST elevation or PTa depression
*ST-depressie,
*Prolonged QT interval
*T-top veranderingen, waarbij diepe negatieve T's over de precordiale afwijkingen het meest frequent worden beschreven
'''Myocardial damage'''
*verlengde QT-tijd.
*New Q waves
*prominente u-golven.
*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
*[[Arrhythmias#Ventricular fibrillation|Ventricular fibrillation]]
*Sinus bradycardia
*Atrial tachycardia


Deze afwijkingen worden frequent beschreven bij [[w:Subarachnoid_hemorrhage|subarachnoïdale bloedingen (SAB)]] (indien serieel gemeten is bij bijna iedere SAB-patiënt op tenminste 1 ECG een afwijkingen te zien), maar ook bij [[w:Subdural_haematoma|subdurale hematomen]], ischemische [[w:Cerebrovascular_accident|CVA]]'s, [[w:Brain_tumor|hersentumoren]], [[w:Guillain-Barre|Guillain Barré]], [[w:Epilepsy|epilepsie]] en bij [[w:Migraine|migraine]]. De ECG afwijkingen zijn over het algemeen reversibel en hebben beperkte prognostische waarde. Toch kunnen de repolarisatieafwijkingen gepaard gaan met myocardschade en echocardiografische afwijkingen. De oorzaak van de ECG afwijkingen is niet geheel duidelijk. Gedacht wordt aan een overstimulatie van het sympathische zenuwstelsel en een daarop volgende "catecholaminestorm".
==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
==Ebstein==
[[File:E000403.jpg|thumb|300px|ECG from a patient with Ebstein's anomaly showing huge P waves and low amplitude QRS waves. RBBB and T wave inversion are not present on this ECG.]]
In Ebstein anomaly the tricuspid valve is inserted more apically than normal. This yields a very large right atrium. About 50% of individuals with Ebstein's anomaly have evidence of Wolff-Parkinson-White syndrome, secondary to the atrialized right ventricular tissue.


==Contusio cordis / Commotio cordis==
Other abnormalities that can be seen on the ECG include
[[w:Cardiac_contusion|Contusio cordis]] (contusio cerebri = 'hersenschudding', contusio cordis dus een 'hartschudding) wordt veroorzaakt door stomp borsttrauma, meestal als gevolg van een auto- of motorongeluk of bij vechtsporten<cite>Maron</cite>. Hierbij kunnen ritmestoornissen optreden of hartfalen. De diagnose wordt gesteld met behulp van bloedonderzoek en echocardiografie.
#signs of right atrial enlargement or tall and broad 'Himalayan' P waves,
Mogelijke afwijkingen op het ECG zijn:<cite>Sybrandy</cite>
#first degree atrioventricular block manifesting as a prolonged PR-interval
#low amplitude QRS complexes in the right precordial leads
#atypical right bundle branch block
#T wave inversion in V1-V4 and Q waves in V1-V4 and II, III and aVF.
#Q waves in II, III, AVF. These Q waves are thought to reflect fibrotic thinning of the right ventricular free wall and/or septal fibrosis with coexisting left posterior hemiblock<cite>khairy</cite>
{{clr}}


'''Niet-specifieke afwijkingen'''
==Left and right bundle branch block==
*Pericarditis-achtige ST elevatie of PTa depressie
See: [[Conduction_delay|Conduction delay]]
*Verlengd QT interval
'''Myocardschade'''
*Nieuw Q golven
*ST-T segment elevatie of depressie
'''Geleidingsstoornissen'''
*Rechter bundeltakblok
*Fasciculair blok
*AV geleidingsstoornissen (1e, 2e, en 3e graads AV blok)
'''Arrhythmieën'''
*Sinustachycardie
*Atriale en ventriculaire extrasystolen
*Boezemfibrilleren
*Ventriculaire tachycardie
*[[Ritmestoornissen#Ventrikelfibrilleren|Ventrikelfibrilleren]]
*Sinusbradycardie
*Atriale tachycardie


==Lown Ganong Levine Syndroom==
Het Lown Ganong Levine Syndrome is een pre-excitatie syndroom waarbij de atria verbonden zijn met onderste deel AV knoop of His. Op het ECG zie je het volgende:
* kort PR interval, < 120 ms
* normaal QRS complex
* geen delta wave
==Linker en rechter bundeltak-blok==
zie: [[Geleidingsvertraging]]


==Cocaine Intoxication==
|<!--col1-->[[Image:JJ00001.jpg|200px]]


==Sarcoidosis==
In patients with proven pulmonary sarcoidosis ECG changes can be used as a marker of cardiac involvement. Presence of a fractionated QRS or a Bundle Branch Block increases the likelihood of cardiac involvement.<cite>schuller</cite>


==Referenties==
{{Box|
==References==
<biblio>
<biblio>
#Sybrandy pmid=12695446
#Sybrandy pmid=12695446
#Rodger pmid=11018210
#Rodger pmid=11018210
#Ferrari pmid=9118684
#Ferrari pmid=9118684
#Aschenbrenner 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 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
#Maron pmid=14681516
#Maron pmid=14681516
#hypoth pmid=2738372
#khairy pmid=18056539
#schuller pmid=21615816
#bb pmid=10866327
</biblio>
</biblio>
}}
[[Category:ECG Textbook]]

Latest revision as of 02:26, 31 May 2012

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 use (digoxin = Lanoxin) are:

  • Oddly shaped ST-depression with 'scooped out' appearance of the ST segment (see figure)
  • Flat, negative or biphasic T wave
  • Short QT interval
  • Increased u-wave amplitude
  • Prolonged PR-interval
  • Sinus bradycardia

ECG changes typical for digoxin intoxication are:

  • Bradyarrhythmias:
    • 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.

Beta blockers

ECG of a patient with atenolol intoxication

Beta blocker intoxication can result in bradycardia, hypotension, QRS widening and seizures. In a series of 260 patients with beta blocker intoxication, 41 (15%) developed cardiovascular morbidity and 4 (1.4%) died. Cardioactive coingestant (e.g. calcium channel blockers) was the only factor significantly associated with the development of cardiovascular morbidity. [1]


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

A patient with myocarditis and pericarditis showing diffuse ST elevation

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 Osborn J wave
Osborn wave. 81-year-old black male with BP 80/62 and temperature 89.5 degrees F (31.94 C).

In hypothermia a number of specific changes can be seen;[2]

  • Sinus bradycardia
  • Prolonged QTc-interval
  • ST segment elevation (inferior and left precordial leads)
  • Osborn-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 [3] 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[4]. Rhythm disturbances and even heart failure can occur. Diagnosis is made using echocardiography and laboratory testing for cardiac enzymes. Possible ECG changes are:[5]

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

Ebstein

ECG from a patient with Ebstein's anomaly showing huge P waves and low amplitude QRS waves. RBBB and T wave inversion are not present on this ECG.

In Ebstein anomaly the tricuspid valve is inserted more apically than normal. This yields a very large right atrium. About 50% of individuals with Ebstein's anomaly have evidence of Wolff-Parkinson-White syndrome, secondary to the atrialized right ventricular tissue.

Other abnormalities that can be seen on the ECG include

  1. signs of right atrial enlargement or tall and broad 'Himalayan' P waves,
  2. first degree atrioventricular block manifesting as a prolonged PR-interval
  3. low amplitude QRS complexes in the right precordial leads
  4. atypical right bundle branch block
  5. T wave inversion in V1-V4 and Q waves in V1-V4 and II, III and aVF.
  6. Q waves in II, III, AVF. These Q waves are thought to reflect fibrotic thinning of the right ventricular free wall and/or septal fibrosis with coexisting left posterior hemiblock[6]


Left and right bundle branch block

See: Conduction delay


Cocaine Intoxication

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Sarcoidosis

In patients with proven pulmonary sarcoidosis ECG changes can be used as a marker of cardiac involvement. Presence of a fractionated QRS or a Bundle Branch Block increases the likelihood of cardiac involvement.[7]


References

  1. Love JN, Howell JM, Litovitz TL, and Klein-Schwartz W. Acute beta blocker overdose: factors associated with the development of cardiovascular morbidity. J Toxicol Clin Toxicol. 2000;38(3):275-81. DOI:10.1081/clt-100100932 | PubMed ID:10866327 | HubMed [bb]
  2. 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]
  3. 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]
  4. 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]
  5. 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]
  6. Khairy P and Marelli AJ. Clinical use of electrocardiography in adults with congenital heart disease. Circulation. 2007 Dec 4;116(23):2734-46. DOI:10.1161/CIRCULATIONAHA.107.691568 | PubMed ID:18056539 | HubMed [khairy]
  7. Schuller JL, Olson MD, Zipse MM, Schneider PM, Aleong RG, Wienberger HD, Varosy PD, and Sauer WH. Electrocardiographic characteristics in patients with pulmonary sarcoidosis indicating cardiac involvement. J Cardiovasc Electrophysiol. 2011 Nov;22(11):1243-8. DOI:10.1111/j.1540-8167.2011.02099.x | PubMed ID:21615816 | HubMed [schuller]
  8. 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]
  9. 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]
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