1. ECG ROUNDS
Navpreet Sahsi

2. “ED Doc to Bed 9”

4. Patient - Sent from Pre-admission clinic because of ECG findings
“I feel fine, I don’t know what the big deal is!”
Asymptomatic, resting comfortably
Obese, 50 years old, male.
Meds: Spironolactone, lisinopril
T- 36.7, HR 70, BP – 205/118, RR 12, 96 % RA
Thoughts?

5. “Oh, and by the way I have these bilateral adrenal tumors.”
Chart shows a recent diagosis of bilateral adrenal tumors -> hypercortisolemia
Does this change anything?

6. ECG Findings in Metabolic/Endocrine Disease

7. The Ultimate “Pimp” Question
What are the “classic” ECG manifestations of pheochromocytoma???

8. ECG in Pheo No “classic” ECG
Often present with ST elevation in a variety of patterns, mimicking acute infarction
Can also present with other ST-T changes, most commonly T wave inversions
QTc often prolonged – risk of arrythmias
Case series – 25 patients with eventual diagnosis of pheo – 17 had abnormal ECG findings, 6 had initial diagnosis of acute STEMI - > urgent angiography - > all were normal
Cardiovascular Manifestations of Pheocromocytoma.AM J Em Med, 18:5; : 2000.
ECG manifestations of endocrine disease. Heart 2001, 86; 679.

11. DONCKIER, J. E et al. Heart 2001;85:679
Copyright ©2001 BMJ Publishing Group Ltd.

13. Hyper K+
Peaked T waves
P wave flattening, PR prolongation, eventual loss of p waves
QRS widening
Sine wave appearance

16. Hypo K Depression of T waves ST depression (> 0.5 mm)
Appearance of U waves

19. Hypothyroidism Sinus brady Low voltage complexes
Prolonged pr and qt intervals
Flattened or inverted T waves
Pericardial effusions occur in 30% of patients and may account for some of the changes

20. Hyperthyroid Sinus Tach – 40 % A. Fib – 10 – 22 %
Nonspecific ST-T abnormalities – 25 %
Interventricular conduction disturbances – LAFB most common – 15 %

22. HyperCa
Shortenes plateau phase (phase 2) of action potential and shortens effective refractory period
ST shortening
Short QT interval

24. Two abnormalities?

26. Hypothermia T < 35.0 Tremor arifact
One of earliest signs – secondary to shivering
Slowing of sinus rate - > bradycardia
Prolongation of PR and QT intervals
Osborn/J wave

27. Osborn or J wave “Camel Hump sign”
Extra deflection off of terminal portion of QRS and ST segment takeoff
Size correlates directly with degree of hypothermia
Usually present when temp < 32.0 deg. C
Can occur in HyperCa, Massive head injury, subarachnoid hemmorrhage

28. Back to the case Cardiology consulted
Not concerned about an acute event because patient completely asymptomatic
Decided to admit patient for pre-op workup since he next in queue for surgery
Led to angiogram - > normal
Booked for surgery