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==Ventricular Aneurysm==
==Ventricular Aneurysm==
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).
The ECG pattern suggests an acute MI. All classical signs of MI may occur:; Q-waves, ST-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==
==Dilated Cardiomyopathy==
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.
Often, a LBBB or broadened QRS-complex can be seen. Additionally, aspecific ST changes are present with signs of left atrial enlargement.


==Hypertrophic Obstructive Cardiomyopathy==
==Hypertrophic Obstructive Cardiomyopathy==
HOCM is een erfelijke aandoening
A HOCM is an heditary illness.
Deze vertonen meestal tekenen van [[ventrikelhypertrofie|linkerkamerhypertrofie]] en [[P_top_morfologie|linkerboezemdilatatie]].
On the ECG there are signs of [[ventricular hypertrophy|left ventricular hypertrophy]] and[P_top_morfologie|left atrial enlargement]].


==Electrolyte disturnbances==
==Electrolyte disturnbances==
Zie het eigen hoofdstuk: [[electrolytstoornissen]]
See chapter: [[electrolyte disturbances]]


==Hypothermia==
==Hypothermia==
Bij onderkoeling vindt men een aantal karakteristieke afwijkingen;
In hypothermia a number of specific chnages can be seen;
* sinubradycardie
* sinubradycardia
* verlenging QTc-interval
* prolonged QTc-interval
* ST-elevatie (onderwand en links-precordiale afleidingen)
* ST-elevation (inferior and left precordial leads)
* Osborne-golven (trage deflexies aan het einde van het QRS-complex)
* Osborne-waves (slow deflexions at the end of the QRS-complex)


[[Image:osborne.gif|thumb| An Osborne J wave]]
[[Image:osborne.gif|thumb| An Osborne J wave]]
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==ECG changes after neurologic events==
==ECG changes after neurologic events==
[[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.]]
[[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 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.  
In 1938, Aschenbrenner <cite>Aschenbrenner</cite> noted that repolarisation abnormalities may occur after increased intracranial pressure. Since then, many publications have occurred discribing ECG changes after acute neurological events.


De ECG afwijkingen die zijn beschreven zijn:  
De ECG changes that may occur are:  
*ST-elevaties,  
*q-waves
*ST-depressie,  
*ST-elevations,  
*T-top veranderingen, waarbij diepe negatieve T's over de precordiale afwijkingen het meest frequent worden beschreven
*ST-depressions,  
*verlengde QT-tijd.
*T-wave changes. Large negative T waves over the precordial leads are observed frequently.
*prominente u-golven.
*prolonged QT-interval.
*prominent u-waves.


Deze afwijkingen worden frequent beschreven bij [[w:Subarachnoid_hemorrhage|subarachnoid_hemorrhage (SAH)]] (indien serieel gemeten is bij bijna iedere SAB-patiënt op tenminste 1 ECG een afwijkingen te zien), maar ook bij [[w:Subdural_haematoma|subdural haematoma]], 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".
These abnormalites 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_haematoma|subdural haematoma]], 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 linited prognostic value. However, the ECG changes can be accompanied with myocardial damage and echocardiographic changes. The cause of the ECG changes is not yet cl;ear. The most common hypothesis is that of a neurotramittor "catecholaminestorm" caused by sympathtic stimulation.


==Contusio cordis / Commotio cordis==
==Contusio cordis / Commotio cordis==
[[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.
[[w:Cardiac_contusion|Contusio cordis]] is caused by a blunt trauma to the chest, often caused by a car- or motorbikeaccident or in martial arts<cite>Maron</cite>. Rhythmdisturbances may occur and even heartfailure. Diagnosis is made using echocardiography and laboratorytesting for cardiac enzymes.  
Mogelijke afwijkingen op het ECG zijn:<cite>Sybrandy</cite>
Possible ECG changes are:<cite>Sybrandy</cite>


'''Not-specific chnages'''
'''Not-specific changes'''
*Pericarditis-achtige ST elevatie of PTa depressie
*Pericarditis-like ST elevation or PTa depression
*Verlengd QT interval
*Prolonged QT interval
'''Myocardschade'''
'''Myocardial damage'''
*Nieuw Q golven
*New Q waves
*ST-T segment elevatie of depressie
*ST-T segment elevation or depression
'''Geleidingsstoornissen'''
'''Conduction delay'''
*Rechter bundeltakblok
*Right bundelbranchblok
*Fasciculair blok
*Fascicular blok
*AV geleidingsstoornissen (1e, 2e, en 3e graads AV blok)
*AV delay(1st, 2nd, and 3rd degree AV blok)
'''Arrhythmieën'''
'''Arrhythmias'''
*Sinustachycardie
*Sinustachycardia
*Atriale en ventriculaire extrasystolen
*Atrial and ventricular extrasystoles
*Boezemfibrilleren
*Atrial fibrillation
*Ventriculaire tachycardie
*Ventricular tachycardia
*[[Ritmestoornissen#Ventrikelfibrilleren|Ventrikelfibrilleren]]
*[[Rhtythmdisturbances#Ventricular fibrillation|Ventricular fibrillation]]
*Sinusbradycardie
*Sinusbradycardia
*Atriale tachycardie
*Atriala tachycardia


==Lown Ganong Levine Syndrome==
==Lown Ganong Levine Syndrome==
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:
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:
* kort PR interval, < 120 ms
* short PR interval, < 120 ms
* normaal QRS complex
* normal QRS complex
* geen delta wave
* no delta wave
==Left and right bundelbranch block==
==Left and right bundelbranch block==
zie: [[Geleidingsvertraging]]
See: [[Conductiondelay]]





Revision as of 15:38, 16 April 2007

Accuracy dispute This article or section is currently being developed or reviewed.
Some statements may be disputed, incorrect or biased.

Medication

Digitalis

Typical for digitalisintoxication is the odd shaped ST-depression

ECG changes typical for digitalisintoxication (digitalis = Lanoxin) are:

  • odd shaped ST-depression.
  • T-wave flat, negative or biphasic
  • Short QT interval
  • Increased u-wave amplitude
  • Prolonged PR-interval
  • Brady-arrhytmias:
    • Sinusbradycardia
    • AV block. Including complete AV block and Wenkebach.
  • Tachyarrhythmias:
    • Junctional tachycardia
    • Atrialtachycardia
    • Ventricular ectopia, bigemini, monomorphic ventricular tachycardia, bidirectional ventricular tachycardia

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

Anti-arhythmics

  • anti-arhythmics: These may lead to several ECG-changes;
    • broad and irregulair 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 arrhtythmias can be seen.

Nortriptyline intoxication

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


Amitriptyline intoxication

An example of a severe amitriptylin intoxication. The inhibitory effect of the sodiumchannel manifests as a broadened QRS complex.
An ECG of the same patient before the intoxication.


Pericarditis

Several stages of pericarditis

Pericarditis is an inflammation of the pericardium. This can lead to ST elevation in all leads. Therefore, it is important to distinguish pericarditis from a myocardial infarction, which has more acute complaints and ST-elevations are limited to the infarct area.

In pericarditis four stages can be used:

  • stage I: ST elevation in all leads. PTa depression (depression between the end of the P-wave and the beginning of the QRS- complex)
  • stage II: pseudonormalisation (transition)
  • stage III: inverted T-waves
  • stage IV: normalisation

Keep into account that in stage I pericarditis, ST-elevation is present in all leads except in aVR, V1 and III.

Myocarditis

Myocarditis is an inflammation of the myocardium and the interstitium. The symptoms are faint chestpain, abnormal heartrate and progressive heartfailure. It can be caused by several factors: viral, bacterial, fungi, parasites, spirochaet, auto-immune, borreliosis (Lyme's disease) and HIV/AIDS.

Acute peri/myocarditis causes aspecific ST changes. These can be accompanied with supraventricular and ventricular rhythmdisturbances and T-wave abnormalities.

Pulmonary embolism

In case of a pulmonary embolism several clinical features may be present:[1]

Pulmonary embolism cannot solely be diagnosed using an ECG, but it may be helpful.

COPD

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

Pacemaker

See the chapter Pacemaker

Tamponade

In case of a tamponade, fluid collects in the pericardium. The pericardium is stiff and the heart cannot pump, because it cannot relax as well. The ECG shows:

  • Sinus tachycardia
  • Low-voltaged 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-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, aspecific ST changes are present with signs of left atrial enlargement.

Hypertrophic Obstructive Cardiomyopathy

A HOCM is an heditary illness. On the ECG there are signs of left ventricular hypertrophy and[P_top_morfologie|left atrial enlargement]].

Electrolyte disturnbances

See chapter: electrolyte disturbances

Hypothermia

In hypothermia a number of specific chnages can be seen;

  • sinubradycardia
  • prolonged QTc-interval
  • ST-elevation (inferior and left precordial leads)
  • Osborne-waves (slow deflexions at the end of the QRS-complex)
An Osborne J wave


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 repolarisation abnormalities may occur after increased intracranial pressure. Since then, many publications have occurred discribing ECG changes after acute neurological events.

De ECG changes that may occur are:

  • q-waves
  • ST-elevations,
  • ST-depressions,
  • T-wave changes. Large negative T waves over the precordial leads are observed frequently.
  • prolonged QT-interval.
  • prominent u-waves.

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

Contusio cordis / Commotio cordis

Contusio cordis is caused by a blunt trauma to the chest, often caused by a car- or motorbikeaccident or in martial arts[4]. Rhythmdisturbances may occur and even heartfailure. Diagnosis is made using echocardiography and laboratorytesting for cardiac enzymes. Possible ECG changes are:[5]

Not-specific 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 bundelbranchblok
  • Fascicular blok
  • AV delay(1st, 2nd, and 3rd degree AV blok)

Arrhythmias

  • Sinustachycardia
  • Atrial and ventricular extrasystoles
  • Atrial fibrillation
  • Ventricular tachycardia
  • Ventricular fibrillation
  • Sinusbradycardia
  • Atriala 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 bundelbranch block

See: Conductiondelay


References

  1. 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]
  2. 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]
  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]

All Medline abstracts: PubMed | HubMed