Tuesday, January 22, 2008

EKG Du Jour

Click to enlarge

It's not everyday a diagnosis falls into your lap.

A 53 year-old man was referred for evaluation because his brother suffered a cardiac arrest at the age of 42. His EKG is above.

Diagnosis? Work-up? Recommendations?

-Wes

12 comments:

Eric, AKA The Pragmatic Caregiver said...

As the rankest of rank amateurs, can I go first so everybody can laugh?

My guess is left ventricular hypertrophy, based on what looks to my untrained eye like a little "lumpiness" of the P-wave in lead I, and the relatively large Rs in V4-6 and aVL.

I guess I'd refer him for an echo or a nuclear stress test, depending on the thickness and luxuriousness of his insurance card.

This is where you can proceed to mocking me shamelessly, and I'll return to my corner licking my wounds. ;0)

Eric

Artemis said...

Wellens sign, (biphasic t waves in V2 and V3) suggests proximal LAD lesion. Patient needs angiography STAT, probable angioplasty and/or stent placement. Brother's history suggests bad genes, so blood pressure and cholesterol evaluation and (likely) lifestyle modification should be underway as well.

Am I right?
A

DrWes said...

Eric -
Not quite, tho' I smiled when I read your suggestions. Don't feel bad - you're trying and that's what matters.

Artemis -
In the differential is LVH, but this just doesn't cut it here (discussion later). EP nerds like myself see this EKG as a "classic" but unfortunately it often goes unrecognized. Hence why it was posted.

R. W. Donnell said...

Here's my differential diagnosis:

1) Brugada syndrome
2) Brugada syndrome
3) Brugada syndrome

Management? THe patient needs Dr. Wes!

The indications for a device may be a bit controversial for an asymptomatic patient. I'll leave that, and whether to do a procainamide challenge test or some other challenge test to Dr. Wes and those of his ilk. Nice look-see diagnosis!

I've blogged about it several times.

DrWes said...

R.W.-

Ah, the seasoned vet wins again. Well done! (Here's the link with references to RW's blog that does a better job of explaining than I could). A previously -performed EKG disclosed no left ventricular hypertrophy and normal cardiac morphology. Blood of the patient and his relatives was sent to Dr. Brugada for genetic evaluation (his lab still does it for free) and a single-lead ICD was installed as the patient was considered high risk for sudden cardiac arrest.

BTW, no procainamide challenge testing needed in this case since the EKG findings are so classic.

The Happy Hospitalist said...

dr Wes, can you guide me throught the "classic" EKG findings in Brugada.

Happy

DrWes said...

Happy-

The classic finding here is the "j-wave" found in V1->V3 at the end of the QRS complex. The "J-point" is where the QRS ends and the ST segment begins. This EKG is classic for a profoundly positive (>2 mm) J wave (not just J point) with its associated convex-up ST segment, followed by a negative last 1/2 of the T wave, suggestive of a Type I Brugada syndrome. More can be found about the EKG criteria here. Realize the ST segment and J-wave amplitude can be dynamic, so if they are not as prominent as this, a Type I antiarrhythmic can be used to provoke the findings - hence the procainamide, flecainide, or ajmaline challenge tests.

Anonymous said...

would you bring other siblings to the ep lab without this ekg finding and try and induce it?
thanks

Anonymous said...

My guess was Brugada as well.
Tx ICD.

Happy - FYI -
Tarascon's Internal Medicine and Critical Care Pocketbook has a "cheat sheet" page on EKG findings in Brugada.

We had a recent consult on a 20 something yo pt whose sibling had a pre-syncopal episode, was evaluated at another facility and had an ICD placed for dx of Brugada. My attending wanted to confirm the dx in the sibling with the ICD and got her EKGs which were abnormal but not classic for Brugada (can't remember the specifics, maybe RBBB). The sibling did not appear to have had provocative tests. Not sure if it was ever resolved as to what to do for the pt.
Do you think that it would be worth doing genetic testing for our pt?

CardioNP

DrWes said...

Anony 10:37-
Given the family hx of sudden cardiac arrest in the family, I would do provocative testing in sibs/immediate family members that do not have definitive signs of Brugada.

CardioNP-
Your case is less clear: primarily because of the family history of "pre-syncope" and unusual baseline EKG. I suspect it's not a "cut-and-dry" case, like this case study. Unfortunately, there's too little space/time to dissect the dx/rx of your patient here, and certainly I cannot second-guess decisions made by others without further detailed information and analysis. Realize that genetic testing is rarely covered by insurers and can cost many thousands of dollars. I'd have to defer to those who know the case better than me as to whether genetic testing should be offered in your case.

larry said...

Dear Dr. Fisher,
Up to which part of ST segment is J Wave?
Thanks,
LW

DrWes said...

LW-

The "J-point" is the location where the ST segment connects to the QRS complex. The "J-wave" on an EKG is seen in hypothermia, and is more commonly called an "Osborn Wave." The Osborn wave is also is found at the junction of the QRS complex and ST segment and has a characteristic appearance. A good example of this can be seen here.