ECG in Non-cardiac Conditions:

“How the ECG can Tell You a

Story”
dr. Victor G. X. Rooroh, Sp.JP
Cardiologist RSUP Prof. Dr. R.D. Kandou
Outline
ECG changes in
• Electrolyte imbalance
• Certain medications
• Pulmonary problems
• Intracranial problems
• Hypothermia
The Effects of Serum Electrolyte
Abnormalities on The ECG
• Phase 4 : Resting Potential is maintained
primarily by the current IK1 through inward
rectifier potassium channels
• Phase 0 : During depolarization, Na+ influx (INa)
results in the rapid upstroke
• Phase 1 : Transient outward potassium current
(Ito) is responsible for partial repolarization
• Phase 2 (plateau) : Slow Ca++ influx (ICa.L)
balanced by K+ efflux (IKs and IKr) and f nal
• Phase 3 : Rapid repolarization results largely from
further K+ efflux .
 Hypokalemia
• Decreased extracellular potassium
causes myocardial hyperexcitability →
arrhythmias.
• Hypokalaemia is defined as a serum
potassium level of < 3.5 mEq/L.
• ECG changes generally do not manifest
until there is a moderate degree of
hypokalaemia (2.5-2.9 mEq/L).
• The earliest ECG manifestation of
hypokalaemia is a decrease in T wave
amplitude
• Mild
Flattening or T wave inversion
• Moderate
- U wave
- PR interval lengthening
- mild ST depression
• Severe
- ST segment depression
- VF
- Torsade de Pointes
Serum K+ = 1.7 mEq/L
• Widespread ST
depression and T wave
inversion
• Prominent U waves
• Long QU interval
Hiperkalemia
• Hyperkalaemia is defined as a serum
potassium level of > 5.2 mEq/L.
• ECG changes generally do not manifest
until there is a moderate degree of
hyperkalaemia (≥ 6.0 mEq/L).
• The earliest manifestation of
hyperkalaemia is an increase in T wave
amplitude.
Serum K+ = 9.3 mEq/L
• Prolonged PR interval.
• Broad, bizarre QRS
complexes — these
merge with both the
preceding P wave and
subsequent T wave.
• Peaked T waves.
Hypocalcemia
Ca = 5.6 mg/dL
• QTc 500ms in a
patient with
hypoparathyroidism
(post
thyroidectomy)
Hypercalcemia
Causes
• Hyperparathyroidism (primary and tertiary)
• Myeloma
• Bony metastases
• Paraneoplastic syndromes
• Milk-alkali syndrome
• Sarcoidosis
• Excess vitamin D (e.g. iatrogenic)
• Normal = 8.4 – 10.7 mg/dL
• Mild = 10.8 – 11.5 mg/dL
• Moderate = 11.6 – 13.5 mg/dL
• Severe = greater than 13.5 mg/dL
Ca= 16.4 mmol/L
• Osborne waves
Hypomagnesemia

• Normal serum = 1.8 – 2.5 mg/dL.

• Hypomagnesaemia, defined as a level
< 1.8 mg/dL, is associated with QT
interval prolongation and an increased
risk of ventricular arrhythmias.
QTC prolonged at 510ms
ECG changes in certain medications
Digoxin
• Digoxin can cause a multitude of dysrhythmias due to:
• Increased automaticity (increased intracellular calcium)
• Decreased AV conduction (increased vagal effects at the AV node)
• Clinical features of Digoxin Toxicity
• GIT: Nausea, vomiting, anorexia, diarrhoea
• Visual: Blurred vision, yellow/green discolouration, haloes
• CVS: Palpitations, syncope, dyspnoea
• CNS: Confusion, dizziness, delirium, fatigue
The presence on the ECG:
• Downsloping ST depression with a characteristics “Salvador Dali sagging”or
“reverse check sign” appearance
• Flattened, inverted, or biphasic T waves
• Shortened QT interval
• Mild PR interval prolongation of up to 240 ms (due to increased vagal tone)
• Prominent U waves
• Peaking of the terminal portion of the T waves
• J point depression (usually in leads with tall R waves)
The morphology of the
QRS complex / ST segment
is variously described as
either “slurred”, “sagging”
or “scooped” and
resembling either a
“reverse tick”, “hockey
stick” or “Salvador Dali’s
moustache”.
ECG changes in pulmonary problems
Chronic Obstructive Pulmonary Disease (Emphysema)

• Low voltage QRS complexes, especially in the left precordial leads (V4-6)
• Low R voltage in the right precordial leads (poor R wave progression)
• Shift of the QRS axis towards +90 degrees (vertical axis; near isoelectric in
lead I) or beyond (right axis deviation)
• Exaggerated atrial depolarisation causing PR and ST segments that “sag”
below the TP baseline
• When pulmonary hypertension develops (cor pulmonale), RVH, RAE,
RBBB will appear in ECG.
• Atrial arrhythmia eg Atrial flutter or atrial tachycardia
Poor R wave Progression QRS Sagging
Cor Pulmonale
• Multifocal AT
• RAD
• RVH
Pulmonary Embolism
• S1Q3T3 pattern
• RAD
• RVH and RBBB are
often seen
ECG changes in intracranial problems
Raised Intracranial Pressure
Causes
• Subarachnoid haemorrhage
• Intraparenchymal haemorrhage (haemorrhagic stroke)
• Massive ischaemic stroke causing cerebral eedema (e.g. MCA
occlusion)
• Traumatic brain injury
• Cerebral metastases (rarely)
Characteristic ECG Abnormalities with
Raised Intracranial Pressure
• Widespread giant T-wave inversions (“cerebral T waves”)
• QT prolongation
• Bradycardia (the Cushing reflex – indicates imminent brainstem herniation)
• ST segment elevation / depression — this may mimic myocardial ischaemia
or pericarditis
• Increased U wave amplitude
• Other rhythm disturbances: sinus tachycardia, junctional rhythms,
premature ventricular contractions, atrial fibrillation
Subarachnoid
Haemorrhage
• Widespread, giant T-
wave inversions
(“cerebral T
waves”) secondary to
subarachnoid
haemorrhage
• The QT interval is also
grossly prolonged (600
ms)
ECG changes in hypothermia
Hypothermia
• Hypothermia occurs when core body temperature is < 35°C
• mild: 32-35°C
• moderate: 28-32°C
• severe: < 28°C
• Swiss staging system
I – clearly conscious and shivering
II – impaired consciousness without shivering
III – unconscious
IV – not breathing
V – death due to irreversible hypothermia
ECG changes in Hypothermia
• Bradyarrhythmias
• Osborne Waves (J waves)
• Prolonged PR, QRS and QT intervals
• Shivering artefact
• Ventricular ectopics
• Cardiac arrest due to VT, VF or asystole
Osborne Waves
Latihan Soal
Kondisi apa yang menyebabkan perubahan segmen ST pada EKG di atas?
A. Hipokalsemia C. Hipokalemia
B. Digoxin D. Hipomagnesemia
Kondisi apa yang menyebabkan perubahan segmen ST-T pada EKG di atas?
A. Hipokalsemia C. Hipokalemia
B. Digoxin D. Hipomagnesemia
Kondisi apa yang menyebabkan perubahan segmen ST-T pada EKG di atas?
A. Hipokalsemia C. Hipokalemia
B. Hiperkalemia D. Hipomagnesemia
Kondisi apa yang menyebabkan perubahan segmen ST-T pada EKG di atas?
A. Hipokalsemia C. Hipokalemia
B. Hiperkalsemia D. Hipomagnesemia
Kondisi apa yang menyebabkan perubahan segmen ST-T pada EKG di atas?
A. Hiperkalsemia C. Hipokalemia
B. Hiperkalemia D. Hipomagnesemia
Manakah yang tidak ditemukan pada gambaran EKG di atas?
A. Vertical axis C. Poor R wave progression
B. RAE D. LVH
Manakah yang tidak ditemukan pada gambaran EKG di atas?
A. S1Q3T3 C. RAD
B. RAE D. incomplete RBBB
Apakah penyebab gambaran EKG di atas?
A. LVH C. Stroke SAH
B. RVH D. Emboli pulmonal
THANK YOU