Hold The Heparin
MORALES, LAURO
ID:1662868
18-JUL-1978 (33 yr)
Male
Hispanic
Vent. rate
PR interval
QRS duration
QT/QTc
P-R-T axes
Room:6673
Loc:0
94
190
96
408/510
57 33
Nicholas Wettersten, MD; Ezra Amsterdam, MD
University of California, Davis Medical Center; Sacramento, CA
19-AUG-2011 MORALES,
11:38:35
LAURO
BPM
ms
ms
ms
90
Normal sinus18-JUL-1978
rhythm
(33 yr)
Vent. rate
Hispanic
PR interval
Nonspecific Male
ST and T wave
abnormality
QRS duration
Prolonged QT
Room:6673
QT/QTc
Abnormal ECG
Loc:0
P-R-T axes
Confirmed by BOMMER MD, WILLIAM (3) on 8/22/2011 11:43:51 AM
Technician: AZ
Test ind:DIZZY
Technician:STAFF ER
Test ind:Hypertension, unspecified
Introduction
DIAGNOSIS:
ID:1662868
Referred by: SHARON WILSON
DIAGNOSIS:
DIAGNOSIS:
78
162
94
410/467
56 27
UCD MED
19-AUG-2011
CENTER 13:38:26
BPM
ms
ms
ms
176
UCD MED CENTER
Normal sinus rhythm
Left ventricular hypertrophy with repolarization abnormality
Abnormal ECG
Confirmed by VENUGOPAL MD, SANDHYA (53) on 8/21/2011 10:42:16 AM
Investigational Studies
Electronically Signed by: WILLIAM BOMMER
Referred
MD by: SHARON WILSON
Electronically Signed by: SANDHYA VENUGOPAL MD
Dynamic ischemic-type electrocardiographic T wave inversions
raise the possibility of myocardial ischemia or infarction but are
I
aVR
actually a non-specific
finding. When dynamic
ischemic-type T
wave inversions are encountered, a full evaluation should be
completed prior to the initiation of definitive therapy.
V1 I
V4 aVR
V1
V4
Learning Objectives
V2 II
V5 aVL
V2
V5
II
•
•
•
aVL
To recognize the broad differential diagnosis of
electrocardiographic T wave inversions
V6 aVF
V3
V6
To considerIIIa central nervous systemaVFprocess with T wave V3 III
ID:1662868
19-AUG-2011 14:20:18
UCD MED CENTER
inversionsMORALES, LAURO
ECG at presentation shows T wave flattening in
ECG two hours after presentation showing T
18-JUL-1978
(33necessity
yr)
Vent.
rate
78 BPMpriorNormal
sinus rhythm
To appreciate
the
of
a
complete
evaluation
to
Male
Hispanic
PR interval
154
ms
ST & T waveV4
abnormality,
consider
inferior ischemia
to
V6
with
U
waves
and
a
prolonged
QT
waves
inverting
in
V4
to
V6
with
U
waves,
a
QRS duration
100
ms
ST & T wave abnormality, consider anterolateral ischemia
initiation Room:6673
ofV1therapy
V1
QT/QTc
432/492
ms
Prolonged QTinterval
with a QTc of 510 msec. QT interval
biphasic T wave in V3 and QT still prolonged with
Loc:0
History
P-R-T axes
Case Presentation
69 68
176
Abnormal ECG
Confirmed by BOMMER MD, WILLIAM (3) on 8/22/2011 11:40:04 AM
highlighted.
Technician:STAFF ER
Test ind:WILSON
II
II
Referred by: SHARON WILSON
DIAGNOSIS:
• A 33-year-old
man presented to the emergency department
with the chief complaint of headache and dizziness.
• Headache started
two days prior. It is described
as throbbing
I
aVR
V5
in nature, located bitemporally, came on gradually over an
10mm/mV
150Hz
7.1.1
12SL 239
CID: 74
hour and 25mm/s
has been
intermittent
since,
rated
4 out of 10 on
pain scale (10 being worse) when it occurs. Achieves
II
aVL
minimal relief
with NSAIDs.
• Dizziness started at approximately the same time as the
headache, but was worse the morning of presentation
prompting patient
to come to the emergency
department.
III
aVF
• He endorsed photophobia, anorexia, nausea, and four
episodes of non-bloody, non-bilious emesis.
• He denied chest pain, dyspnea on exertion, orthopnea,
V1
paroxysmal dyspnea,
abdominal pain, or diarrhea.
Medications
• None
QTc of 480 msec. Inverted T waves highlighted.
V1
Electronically Signed by: WILLIAM BOMMER MD
V4
V5
25mm/s
10mm/mV
EID:3150Hz
EDT: 11:43
7.1.1
22-AUG-2011
12SL 239ORDER:
CID: 72629467
139
ACCOUNT: 020020589634
Page 1 of 1
V2
V5
V3
V6
ECG three hours after presentation showing further
deepening of T wave inversions in V4 to V6 with U
waves, T wave now inverted in V3, and QTc of 505
msec. U waves highlighted.
Past Medical History
• Hypertension and Type 2 Diabetes Mellitus
V5
Family History
25mm/s
10mm/mV
150Hz
7.1.1
12SL 239
CID: 139
• Hypertension – Mother and Father
Social History
• Smoke 0.5 packs per day for five years, quit two years prior
Physical Exam
Blood pressure: 255/170 mmHg; Heart Rate: 109/min
General: Patient was alert in mild distress from headache.
Fundoscopic exam: No papilledema
Cardiac exam: Tachycardic, apical impulse was non-displaced
and there was no murmur, gallop, or rub
Neurologic exam: Normal strength, sensation, coordination, and
proprioception throughout; reflexes were brisk and symmetric
bilaterally and cranial nerves were intact
• T wave alterations are a non-specific finding with a broad
differential which includes:
• acute coronary syndrome
• central nervous system event
• pulmonary embolus
• Wellens’ syndrome
• left ventricular hypertrophy with strain
• digitalis effect
• bundle branch block
• pre-excitation
• persistent juvenile pattern.1,2
• ECG changes during CNS events have been described with:
• subarachnoid hemorrhage (SAH)
• cerebrovascular accident
• intracerebral hemorrhage
• Trauma
• CNS mass.1-3
• ECG findings classically described with CNS events include:
• QTc prolongation (≥460 msec)
• T wave inversion
EID:53 EDT: 10:42 21-AUG-2011 ORDER: 72635768 ACCOUNT: 020020589634
• prominent U wave (≥100 µV amplitude)
Page 1 of 1
• ST segment elevation
• ST segment depression.3,4
• In a study of 100 patients with SAH, these changes were
noted in 16%, 7%, 15%, 9%, and 3% of patients,
respectively, with at least one of these findings seen in a total
of 41% of patients.
Non-contrast head CT showing a hemorrhage in
the left thalamus with extension into the the third
ventricle.
Additional Studies:
II
Discussion
Troponin (ref, <0.04 ng/ml): 0.23 (at 0 hr), 0.23 (at 1 hr), 0.21 (at 3 hr)
Echocardiogram: mild concentric left ventricular hypertrophy (LV), normal LV and right ventricular
systolic function, impaired LV diastolic function, and mild regurgitation of the aortic, mitral, and tricuspid
valves
EID:3 EDT: 11:40 22-AUG-2011 ORDER: 72632910 ACCOUNT: 020020589634
Page 1 of 1
Hospital Course
• Cardiology was consulted for consideration of acute coronary syndrome and initiation of aspirin,
clopidogrel and intravenous heparin therapy.
• While being evaluated by Cardiology, the head CT was completed showing intracranial hemorrhage.
• The patient was diagnosed with hypertensive emergency with a spontaneous intracranial hemorrhage.
• The patient was admitted to the ICU and placed on a nicardipine infusion for blood pressure control.
• No acute management was required for the intracranial hemorrhage and repeat imaging on hospital day
4 showed a decrease in extent of the hemorrhage.
• Evaluation for secondary causes of hypertension was negative for renal artery stenosis,
hyperaldosteronism, and pheochromocytoma.
• An ECG on hospital day 7 showed resolution of T wave inversion in V3 and decreased depth of the T
wave inversions in V4-V6.
• The patient was transitioned to oral anti-hypertensive therapy, requiring a total of five medications, and
discharged on hospital day 11.
• Other noted ECG abnormalities reported include:
• sinus bradycardia
• premature ventricular contractions
• atrial fibrillation
• first-degree heart block.5
• In a study of 110 patients with intracranial hemorrhage,
excluding stroke and SAH, ECG abnormalities were noted in
64% of patients with rhythm disturbances listed above being
the most common abnormality (69%).
• Similar rhythm disturbances have also been reported with
SAH.3
References
1. Catanzaro JN, Meraj PM, Zheng S, Bloom G, Roethel M, Makaryus AN.
Electrocardiographic T-wave changes underlying acute cardiac and cerebral events. Am J Emerg
Med. Jul 2008;26(6):716-720.
2. Hayden GE, Brady WJ, Perron AD, Somers MP, Mattu A. Electrocardiographic T-wave
inversion: differential diagnosis in the chest pain patient. Am J Emerg Med. May 2002;20(3):252262.
3. Perron AD, Brady WJ. Electrocardiographic manifestations of CNS events. Am J Emerg
Med. Oct 2000;18(6):715-720.
4. Sommargren CE, Zaroff JG, Banki N, Drew BJ. Electrocardiographic repolarization
abnormalities in subarachnoid hemorrhage. J Electrocardiol. 2002;35 Suppl:257-262.
5. Maramattom BV, Manno EM, Fulgham JR, Jaffe AS, Wijdicks EF. Clinical importance of
cardiac troponin release and cardiac abnormalities in patients with supratentorial cerebral
hemorrhages. Mayo Clin Proc. Feb 2006;81(2):192-196.
Acknowledgements
Thanks to Dr. Amsterdam for his tireless efforts working on this case with me.