ECG IN COVID 19

DR AZERIN OTHMAN
HRPZ II , KOTA BHARU.
 SARS-CoV-2
Hypercoagulability Pulmonary
embolism

Microvessels

Microvascular
dysfunction

Downloaded from https://academic.oup.com/eurheartj/advance-article/doi/10.1

Coronary
artery
Acute coronary

Viral invasion
Endothelial
dysfunction
syndromes
• Same ECG diagnostic
Plaque
instability/
criteria in COVID 19
& Non COVID 19
rupture

Inflammation/
cytokine storm
population
Heart failure

Myocardial
damage

Arrhythmia

ular involvement in COVID-19—key manifestations and hypothetical mechanisms. SARS-CoV-2 anchors on transmembrane
COVID WITH PULMONARY EMBOLISM (PE)

Source : Eur Heart J, Volume 42, Issue 33, 1 September 2021, Pages 3127–3142.
 ECG - PULMONARY EMBOLISM (PE)

• Dilation of the right atrium and right ventricle with consequent shift in the
position of the heart.
ECG in Pulmonary
embolism due to • Right ventricular ischaemia.
• Increased stimulation of the sympathetic nervous system due to pain, anxiety
and hypoxia.

❖ The ECG is neither sensitive nor specific enough to diagnose or exclude PE.
❖ Around 18% of patients with PE will have a completely normal ECG.

HIGHER PREDICTIVE OR DIAGNOSTIC VALUE WHEN COMBINED WITH

CLINICAL PICTURE & OTHER TOOLS - eg Echocardiography findings.
 ECG - PULMONARY EMBOLISM (PE)

❖ Sinus tachycardia - the commonest - 44 % of PE . ❖ Dominant R wave in V1 - sign of acute RV dilatation.

❖ RBBB ( complete or partial ) - 18 % of PE. ❖ P Pulmonale - sign of RA dilatation - 9 % of PE.

- peaked P wave in lead II > 2.5 mm in height.
❖ RV strain pattern - T wave inversions in V1-4.
± ❖ S1 Q3 T3 - deep S in I, Q in III,inverted T in III.
inferior leads (II, III, aVF). This “classic” finding is neither sensitive nor specific for PE.

high pulmonary artery pressures. - 20 % of PE.

- 34% of PE.
❖ Atrial tachyarrhythmias - AF, A/Flutter , atrial tachycardias.
❖ Right axis deviation (RAD) - 16 % of PE. - 8% of PE.
 ECG - PULMONARY EMBOLISM (PE)

• Sinus tachycardia

• S1Q3T3

• RBBB

• RV strain pattern
 ECG - PULMONARY EMBOLISM (PE)

• Sinus tachycardia

• S1Q3T3

• RBBB

• RV strain pattern

• Right axis deviation

 ECG - PULMONARY EMBOLISM (PE)

• Sinus tachycardia

• RV strain pattern

• Right axis deviation

 Differential diagnosis of pulmonary
embolism by ECG

• COPD
• Pulmonary hypertension
• Asthma
• Severe Pneumonia , ARDS
• Chronic lung disease
• Pneumothorax
• OSA
 DIAGNOSIS OF PULMONARY EMBOLISM

CTPA OR CLINICAL DIAGNOSIS

1. Clinical probability based on :

- clinical judgement
- validated prediction score
±
2. Supportive tools
Unable to
Definite
- Echocardiography do CTPA
diagnosis - ECG
- Compressive U/S lower limbs
 COVID WITH PERICARDITIS

❖ The incidence of pericarditis in acute covid infection : scarce,

Literatures : on going publishing, most as case reports.

❖ Can coexist with myocarditis as ▪︎ myopericarditis

▪︎ perimyocarditis

❖ The incidence of pericarditis either solely or together with myocarditis

post vaccination : rare , mild in younger population & resolved within few
days or weeks.
 ECG - PERIC ARDITIS
• Stage 1 : widespread ST elevation and PR depression with reciprocal PR elevation in aVR
±
down sloping TP segment ( Spodick’s sign )
( occurs during the first 2 weeks )

ECG in pericarditis • Stage 2 : normalisation of ST changes; generalised T wave flattening.

has 4 stages ( 1 to 3 weeks )

• Stage 3 : flattened T waves become inverted.

( 3 to several weeks )

• Stage 4 : ECG returns to normal.

( several weeks onwards )

❖ Less than 50% of patients progress through all four classical stages and evolution of changes may not follow this
typical pattern.
❖ Most helpful in diagnosis if ECG in stage 1.
 Stage 1 : widespread ST elevation and PR depression
Most helpful with reciprocal PR elevation changes in aVR
ECG in diagnosis ±
of pericarditis down sloping TP segment ( Spodick’s sign ) - best in II

ST elevation and PR depression PR elevation changes in aVR Down sloping TP segment ( Spodick’s )
 ECG - PERIC ARDITIS

• ST elevation concave
- widespread

• PR depression
- inferior leads
- lateral leads

• PR elevation
- aVR

• Spodick’s sign
- V6
 ECG - PERIC ARDITIS

• ST elevation concave
- widespread

• PR depression
- inferior leads
- lateral leads

• PR elevation
- aVR
 ECG - PERIC ARDITIS

• ST elevation concave
- widespread

• PR depression
- inferior leads
- lateral leads

• PR elevation
- aVR
 Differential diagnosis of pericarditis
by ECG

• STEMI
• Benign early repolarization
• Myocarditis
• LV aneurysm
• Hyperkalaemia
 DIAGNOSIS OF PERIC ARDITIS

CARDIAC MRI OR AT LEAST 2 OF THESE

1. Non ischaemic chest pain- pleuritic.

Helpful in
2. Pericardial rub. acute stage

3. ECG changes - mainly stage 1 ECG features.

Latest ,more
complete info 4. Pericardial effusion - new or worsening.
 COVID WITH MYOCARDITIS

❖ Myocarditis is a rare but serious complication of COVID -19 infection &

COVID -19 mRNA vaccination.

❖ A study showed a rate of acute myocarditis of 2.4 per 1000 patients

hospitalized with COVID-19.

❖ Higher rate & severity of acute myocarditis linked to COVID-19 infection

compared with myocarditis cases linked to the mRNA COVID-19 vaccines.

❖ The incidence of myocarditis post vaccination : rare , mild in younger

population & resolved within few days or weeks.
 DIAGNOSIS OF COVID 19 LINKED MYOCARDITIS

PRESENCE ELEVATED ECG ENDOMYOCARDIAL

OF CARDIAC ✚ TROPONIN ✚ and or ✚ BIOPSY
SYMPTOMS LEVEL ECHOCARDIOGRAPHY and or
ABNORMALITIES CARDIAC MRI
• Chest pain
• Dyspnoea
• Palpitation
• Syncope
etc

YES YES YES YES

DEFINITE MYOCARDITIS *

* In the absence of significant pre existing CVS disorders or CAD.

Source : 2022 ACC Expert Consensus Decision Pathway on Cardiovascular Sequelae of COVID-19 in Adults: Myocarditis and Other Myocardial Involvement
 DIAGNOSIS OF COVID 19 LINKED MYOCARDITIS

PRESENCE ELEVATED ECG ENDOMYOCARDIAL

OF CARDIAC ✚ TROPONIN ✚ and or ✚ BIOPSY
SYMPTOMS LEVEL ECHOCARDIOGRAPHY and or
ABNORMALITIES CARDIAC MRI
• Chest pain
• Dyspnoea
• Palpitation
• Syncope
etc

YES YES YES NO

POSSIBLE MYOCARDITIS
 DIAGNOSIS OF COVID 19 LINKED MYOCARDITIS

PRESENCE ELEVATED ECG ENDOMYOCARDIAL

OF CARDIAC ✚ TROPONIN ✚ and or ✚ BIOPSY
SYMPTOMS LEVEL ECHOCARDIOGRAPHY and or
ABNORMALITIES CARDIAC MRI
• Chest pain
• Dyspnoea
• Palpitation
• Syncope
etc

YES YES YES YES LATER IN F/U *

PROBABLE MYOCARDITIS

• * Biopsy and or cardiac MRI done in followup (within 6 months).

• Myocardial involvement : myocardial abnormalities which neither fulfill criteria of definite, possible or probable myocarditis
• Myocardial injury : isolated elevated troponin level.
ELEVATED
TROPONIN
LEVEL
 ECG - MYOCARDITIS

• Sinus tachycardia
• Non specific ST segment changes - ST elevation or depression
• Non specific T wave changes - T wave inversion
ECG in myocarditis • AV block : 1º, 2º, 3º block
are variable
• Intraventricular block - BBB, non specific IVCD
• Arrhythmias - supraventricular , ventricular , brady or tachyarrhythmias
• Prolonged QT
• Co exist with pericarditis ( if involved inflammation of adjacent pericardium )
 ECG - MYOC ARDITIS

• Sinus tachycardia

• Non specific ST
segment changes
 ECG - MYOC ARDITIS

• ST elevation
- widespread
 ECG - MYOCARDITIS

• ST depression
- widespread
 ECG - MYOC ARDITIS

• T wave inversion
 ECG - MYOC ARDITIS

• VT
 ECG - MYOC ARDITIS
• ST elevation
- mimic STEMI
 Differential diagnosis of myocarditis
by clinical

• Acute coronary syndrome

• Sepsis related cardiomyopathy
• Stress induced cardiomyopathy
• Any cardiomyopathy !!
 Differential diagnosis of myocarditis
by ECG

• Any thing !!!

 COEXISTING MYOCARDITIS & PERICARDITIS

DISEASE / CONDITION

PERICARDITIS MYOCARDITIS

Fulfilled Fulfilled
criteria of criteria of
pericarditis myocarditis
 COEXISTING MYOCARDITIS & PERICARDITIS

MYOPERICARDITIS PERIMYOCARDITIS

• At least 2 of 4 clinical criteria of • At least 2 of 4 clinical criteria of

pericarditis pericarditis

+ +
• Raised troponin • Raised troponin

+ +
• Echo : No wall motion abnormality • Echo : Wall motion abnormality
and Good LV function and or impaired LV function