ECG ATLAS 2

ECG Atlas: 2

Eponymous ECGs

Vigneshvarprashanth Umapathy¹*, G. Dominic Rodriguez², Ivan A Jones³

¹Resident Internal Medicine, Kauvery Hospital, Tennur, Trichy, India

²HOD Internal Medicine, Kauvery Hospital, Tennur, Trichy, India

³Consultant Internal Medicine, Kauvery Hospital, Tennur, Trichy, India

*Correspondence: [email protected]

Case Presentation

Case 1

A 55-year-old gentleman who was planned for below knee amputation inview of diabetic foot complained of non-radiating chest pain. An ECG taken immediately was unremarkable. But an ECG taken after the resolution of chest pain showed biphasic T waves in leads V2, V3 and V4. This pattern is called the Wellens pattern A suggestive of proximal LAD occlusion. Loading dose was given. Troponin I was normal. Coronary angiography revealed triple vessel disease with 95% ostial LAD occlusion. He was planned for CABG.

There are 2 patterns of Wellens syndrome, type A and B [1]

Type A: Bisphasic T waves with initial positivity and terminal negativity. This is seen in 25% of cases.

Type B: Deeply and symmetrically inverted T waves. This is seen in 75% of cases.

Clinical importance

Wellens syndrome indicates critical LAD occlusion. These patients may suffer cardiac arrest soon, do poorly with medical management alone and usually require coronary angiogram and subsequent revascularisation. Wellens syndrome is considered as a STEMI equivalent. The patients are often free of chest pain at the time of this classical ECG finding and the cardiac enzymes may be normal or only minimally elevated. Hence, this syndrome could be easily missed leading to potentially lethal outcomes.

Case 2

A 78-year-old elderly gentleman presented to the emergency department with complaints of dyspnoea, cough with expectoration and fever. On examination, he had barrel chest, bilateral extensive wheeze and bilateral crepitations. A diagnosis of acute infective exacerbation of COPD was made and he was treated with bronchodilators, antimicrobials and other supportive measures. ECG done as a part of workup showed deeply symmetrical T wave inversions in precordial leads (V2-V6) with T wave inversion in inferior (II, aVF) and lateral leads (I, aVL) suggestive of Apical Hypertrophic Cardiomyopathy and premature atrial complexes. Echocardiography also revealed left ventricular hypertrophy. However, he did not have any cardiovascular symptoms and his left ventricular function was normal.

Apical hypertrophic cardiomyopathy is a non-obstructive variant of hypertrophic cardiomyopathy. This relatively uncommon form of HCM is seen most frequently in Japanese patients. Apical HCM constitutes up to 25% of all HCM cases in Japan. This is also known as Yamaguchi syndrome, named after Hiroshi Yamaguchi. The classic ECG finding in apical HCM is giant T-wave inversion in the precordial leads. Inverted T waves are also commonly observed in the inferior and lateral leads [2].

Case 3

An 83-year-old elderly gentleman known to have diabetes mellitus, hypertension was admitted for encephalopathy which was found to be due to hyponatremia. During his hospital stay, he developed chest pain and the ECG was done. ECG showed sinus tachycardia, left axis deviation, left bundle branch block (LBBB), notching of upstroke of S wave in leads V2-V4, horizontal ST depression in leads I and aVL, and prolonged QT interval. Tropinin I was positive. Echocardiography revealed severe left ventricular dysfunction with an ejection fraction of 30%. Coronary angiogram was not done as attendants were not willing and he was managed medically.

The notching in the ascending limb of S wave in leads V3, V4 is referred to as the Cabreras sign. This sign is often indicative of old myocardial infarction (MI) in presence of LBBB. This ECG sign was first described by Cabrera and Friedland in 1953. Although Cabrera’s sign has ahigh specificity for the diagnosis of an old myocardial infarction in LBBB, it has a poor sensitivity [3].

References

Life in the Fast Lane Blog, Wellen Syndrome, https://litfl.com/wellens-syndrome-ecg-library
Life in the Fast Lane Blog, Apical hypertrophic cardiomyopathy, https://litfl.com/apical-hypertrophic-cardiomyopathy-ahc
Cabrera E, Friedland C. La onda de activación ventricular en el bloqueo de rama izquierda con infarto: un nuevo signo electrocardiográfico. Arch Inst Cardiol Mex. 1953;23(4):441-60.

Dr. Vigneshvarprashanth Umapathy

Resident Internal Medicine

Dr. G. Dominic Rodriguez

HOD Internal Medicine

Dr. Ivan A. Jones

General Medicine specialist