Sinus rhythm ECG:

Is it always normal?
Rerdin Julario
Electrophysiology and Pacing Division
Dr Soetomo General Hospital
Surabaya
Is it Normal?

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Outline of Dangerous ECG characteristic

Pericardial Effusion

Pulmonary Embolism

ST segment Elevation

T waves

Electrolyte

Digoxin effect and Cocaine

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 Pericardial Effusion

Sinus tachycardia 120 bpm,

Low QRS voltages
Electrical alternans ( alternating tall and short QRS complexes)
 Pericardial Effusion

Clinical Presentation

Shortness of breath or dyspnea

Discomfort when breathing while lying
down
Chest pain
Chest fullness

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 Pulmonary Embolism

Most common is ST
S1, Q3,T3 this term called
McGinn-White sign
Right Strain (RBBB pattern)
Inversion anterior T wave
Recent studies ECG finding in
PE is Anterior T wave
inversion
Mattu et al, Inversion T waves
anteriorly and inferior lead
specific for PE

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 Pulmonary Embolism
Shortness of breath
Sudden, sharp chest pain that may become worse with deep
breathing or coughing
Tachycardia, Sweating, Anxiety
Signs of shock

Mortality rate was high 15%

S in lead1

Q in leadIII
T inversion in leadIII

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 T wave inversion in PE
Number of Leads with T wave
inversion correlating with RV
dysfunction on Echo :
≤ 3 = 47%
4-6 = 92%
≥ 7 = 100%

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 ST segment elevation

Differential diagnosis
◦ Myocardial Infarction
◦ Pericarditis
◦ Early Repolarization
Myocardial Infarction

Tall, peaked T waves in the area of

ischemia may be the first sign of tissue
injury. These tall T waves are identical to
those seen in hyperkalemia, but are
localized to the leads “looking at” the area
of injury. These waves are probably due to
potassium leaking through damaged
membranes.

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 Pericarditis
Chest pain is the cardinal symptom of pericarditis,usually precordial or
retrosternal with referral to the trapezius ridge, neck, left shoulder, or arm.

Stage I (acute phase): Diffuse concave upward

ST segment elevation in most leads, PR
depression in most leads (may be subtle), and
sometimes notching at the end of the QRS
complex

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Pericarditis

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Differentiating ECG AMI vs Pericarditis

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Early Repolarization

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 T Waves Inversion

CAD Ischemia
Cardiomyopathies
CNS Infarction

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 Wellens Syndrome
Pure T wave abnormality in V2-V3
Classically, occurs during pain free period
Assosiated with critical proximal LAD

Deep inversed symmetric T

waves (75% case ) “non spesific”

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 Hypertrophic Cardiomyopathy

Diffuse T-wave inversion in precordial (V4-6) and standard (II,III,VF)

leads (60%)

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 Intracranial Haemorrhage
Widespread, giant T wave inversions
Grossly prolonged QT interval (~ 600ms)
This ECG pattern is characteristic of raised intracranial pressure and is
classically seen in the context of massive intracranial haemorrhage ext

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 Tall T waves

Hyperacute T waves/ Ischemia

Hyperkalemia

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 Electrolyte Disturbance
Hyperkalemia
Hyperkalemia is defined as potassium level > 5.5 mEq/L
Severe hyperkalemia is serum potassium level > 7.0 mEq/L
Peaked T waves (usually earliest sign ) >5.5mEq/L
Above 7 mEq/L assosiated with conduction abnormalities, bradycardia
and cardiac arrest

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These include :

T wave inversions
Flattened T waves
an increased U wave
a prolonged PR interval
ST segment depression
with a distinct “scooped “
appearance
short QT interval

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Cocaine prolongs the PR, QRS, and QT intervals

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