E.C.G.

Course –VIII
Electrolytes
disorder, drug
toxicities and QT
segment
prolongation
Dr. Michael Kassirer

”Dept. Internal Medicine ”D

Tel-Aviv Medical center
 Objective
By the end of lesson 8 the student will:
 Describe the electrocardiographic effect of
different electrolytes (hypo- and hyper-
conditions) on the ECG pattern.
 Know the electrocardiographic effect of
digoxin intoxication.
 Know how to calculate QTc,
 Depolarizatin-
Repolarization

90mV-

ICF

+
Na ECF
+
K Ca
++
+
Na Ca
++
K
+
 Hyperkalemia

High, tented T wave

 Wide QRS complex
Sine wave
 Decreased R amplitude
 P wave disapears
 Hypokalemia

 Prolonged QT
 Decreased, or inverted T
 Increased U wave
Hypo / hypercalcemia

Hypocalcaemia effect:
 ST segment prolongation →
↑QTc
 PR shortening

 Clinical symptoms
Long QT paterns
 QT segment
 Prolonged QT segment
male: QTc ≥ 0.45msec
female: QTc ≥ 0.46msec

 Heart rate effect on QT segment

↑ HR → ↓ QT time (sec)
QTc
↓ HR → ↑ QT time (sec)
= QT/√RR
 Prolonged QT

QT =0.64

RR RR = 1.24

QT √ RR = 1.114

QTc = QT/√ RR =
0.57
 Torsade de pointes
 Non-stable arrhythmia – converts to normal sinus
or VT/VF
 The longer the QT – the higher the risk
 Typical arrhythmia with long QT
 Risk factors for
prolonged QT
 Congenital long QT (Familial or
sporadic)
 Hypokalemia, Hypomagnasamia
 Drugs
 Liver or Kidney failure
 Organic heart disease (LVH, CHF)
Drugs that prolongQT

Probable and
Possible Improbable
Very Probable
Antiarrhythmi Anti-psychotic: Anti-
c:s Chlorpromazine depressant:
Amoidarone Haloperidole Fluoxatine
Disopyramide Risperidone Paroxetine
Procainamide Anti- Anti-Migrane
Quinidine :depressant :Antibiotics
Sotalol Amitryptiline Levofloxacin
Anti- Imipramine Co-trimoxazole
:psychotic :Antibiotics Fluconazole
Pimozide Clarithromycin Foscarnet
Ziprasidone Erythromycin
Thioridazine Pentamidine
Digitalis effect
 Digoxin toxicity

 APBs, VPBs
 Atrial tachycardia
 AV nodal blocks
 Accelerated junctional rhythm
 ”Regular” Atrial fibrillation (AF +CAVB +AcJR(
 Clinical signs – Anorexia, nausea, vomiting, visual
changes