Electrocardiographic T-wave changes underlying acute cardiac and cerebral events

Intracranial Hemorrhage Presenting With ST-Segment Elevation and T-Wave Inversion Concerning for Acute Myocardial Infarction

Acute neurologic injury and increased intracranial pressure are associated with electrocardiographic (ECG) changes that include rhythm disturbances as well as ECG mimics of myocardial ischemia, such as focal or diffuse ST-segment or T-wave abnormalities. Both the mechanism and significance of these ECG changes are not clear. The authors report a case of a patient with a complex medical history who became hypotensive after he presented with acute intracranial hemorrhage. A subsequent ECG showing ST-segment elevation in the inferior and lateral leads was concerning for acute myocardial infarction. ST-segment elevation in the setting of acute intracranial hemorrhage can lead to diagnostic confusion and/or premature narrowing of the differential diagnosis. This case report starts with an example of this exact scenario, provides a concise overview of potential mechanisms, and concludes with several possible strategies that the emergency provider can use to identify this effect in an undifferentiated patient.

Changes in Electrocardiogram in Patients With Spontaneous Subarachnoid Hemorrhage: A Cross-Sectional Study

Background Electrocardiographic (ECG) changes are frequently reported findings in patients with subarachnoid hemorrhage (SAH). We conducted a retrospective descriptive study to assess the prevalence of electrocardiographic changes in patients with non-traumatic SAH.  Methods In this single-center retrospective cross-sectional study, ECG recordings of 45 patients who presented to Tribhuvan University Teaching Hospital in the year 2019 with SAH were collected and analyzed to detect any abnormalities.  Results In our study, 88.8% of patients had some form of ECG abnormality. The most common ECG abnormalities associated with SAH were QTc prolongation, T-wave abnormalities, and bradycardia, which were found, respectively, in 35.5%, 24.4%, and 24.4% of the patients. Other ECG changes we observed include ST depression, large U-waves, atrial fibrillation, and premature ventricular contractions. Conclusion Morphological and rhythm abnormalities are frequently observed in patients with SAH, which may cause diagnostic dilemmas and unnecessary workups. Further studies are required to evaluate their significance and correlate ECG changes with clinical outcomes.

T-wave Inversions in Cerebellar and Occipital Lobe Infarcts in the Setting of Deep Vein Thrombosis and Pulmonary Embolism Suggestive of Paradoxical Emboli: A Case Report

Cardiological causes account for the majority of acute electrocardiographic (ECG) changes. The reason for this fear is the irreversibility of myocardial necrosis. Generally, various changes can be observed in the ECG, including ST-T changes, QTc prolongation, arrhythmias, and T-wave inversions. Even though T-wave inversions can be seen in myocardial ischemia/infarction, they are rarely seen in acute cerebrovascular accidents (CVAs). We present the case of a 66-year-old woman who initially presented at our facility with dizziness in the context of orthostatic hypotension. An initial cardiac evaluation revealed no cardiac involvement. She was treated with intravenous fluids (IVF), which improved her symptoms. The patient's mental status was markedly altered approximately four days after admission. In this instance, she was found to have abnormal ECG findings (not previously observed on the ECG that was obtained on the day of admission), elevated troponin T levels, as well as elevated pro-B-type natriuretic peptide (pro-BNP). The patient was given aspirin and clopidogrel immediately and was placed on a heparin drip for a suspected non-ST elevation myocardial infarction (NSTEMI). A non-contrast computed tomography of the head revealed an acute cerebrovascular accident (CVA), following which the heparin drip was stopped. The patient was then transferred to another acute care facility capable of performing neurosurgical interventions. Additionally, a computed tomography angiography (CTA) of the chest and lower extremities venous duplex showed bilateral pulmonary emboli and deep venous thrombosis (DVT), respectively.

Transient Cardiac Dysfunction Following a Cerebrovascular Accident

Acute cerebral injuries are often accompanied by sudden electrocardiogram (ECG) changes such as cardiac arrhythmias, QT prolongation, and abnormal T-wave morphology. One rare phenomenon is “cerebral T-waves”, which are T-waves observed in the context of stroke and described as transient, symmetric, and deeply inverted. The classic cerebral T wave is defined as a T-wave inversion of ≥5 mm depth in at least four contiguous precordial leads, and it is more commonly observed in the setting of acute ischemic stroke rather than hemorrhagic stroke. We describe the case of a patient who initially presented with acute pulmonary edema, T-wave inversions in the precordial leads, and left ventricular dysfunction on echocardiogram raising suspicion of an ischemic cardiac event. However, a brain CT scan performed on the third day of admission proved us wrong.

Transient Cardiac Dysfunction in Cerebrovascular Accidents

Acute cerebral injuries have been repeatedly correlated with sudden and different electrocardiogram (EKG) changes, such as cardiac arrhythmias, QT prolongation, and abnormal T-wave morphology. One rare phenomenon is “cerebral T-waves,” which are T-waves observed in the context of stroke and described as transient, symmetric, and deeply inverted. Moreover, few studies linked acute cerebral injuries with transient cardiac dysfunction secondary to autonomic dysfunction.

The classic cerebral T-waves are defined as a T-wave inversion of ≥5 mm depth in ≥4 contiguous precordial leads, and it is more commonly observed in the setting of acute ischemic stroke rather than hemorrhagic stroke. We present a patient who presented with acute pulmonary edema, T-wave inversions in the precordial leads, and left ventricular (LV) dysfunction initially suspicious for acute coronary syndrome (ACS). However, computer tomography of the brain performed on the third day of his hospital stay proved us wrong.

Prognosis of Early-Stage Continuous Electrocardiogram Abnormalities on Patients with Acute Ischemic Stroke

BACKGROUND

To explore the effects of onset time of electrocardiogram (ECG) abnormalities at an early stage of acute ischemic stroke on patient prognosis. Cardiac dysfunction after stroke is a challenge for clinicians. This is a retrospective study of patients in the neurology departments of 23 hospitals in Shanghai and Wuhan, China.

METHODS

The medical records of 351 patients were compared. Chi-square, Kruskal-Wallis, Mann-Whitney U tests, and stratification compared subgroups. Logistic regressions analyzed factors associated with modified Rankin Scale (mRS) score.

RESULTS

ECG abnormalities occurred in 70.1% of patients at an early stage (most were within 48 hours of disease onset) at least once, whereas 45.9% of the patients had ECG abnormalities within 48 hours of onset and at 7 days after onset. The incidence of poor prognosis (mRS >1) was significantly higher in the patients with ECG abnormalities for both time points than that in those with normal ECGs (56.3% versus 32%, odds ratio = 2.166). Most patients demonstrated 1 to 2 ECG abnormalities, and very few patients had 3 or more. Increasing number of ECG abnormalities was mirrored by poorer prognosis. ECG abnormalities occurred within 48 hours and at the seventh day after onset of acute ischemic stroke; the abnormalities that appeared within 48 hours and were still found on the seventh day after onset of the disease were independent predictors of poor patient prognosis.

CONCLUSIONS

The incidence of abnormal ECGs was high in the patients with acute ischemic stroke, and the abnormal ECGs could appear at any stage of the disease.

Electrocardiographic abnormalities in acute cerebrovascular events in patients with/without cardiovascular disease

Objectives:

Electrocardiographic (ECG) changes are reported frequently after acute strokes. It seems that cardiovascular effects of strokes are modulated by concomitant or pre-existent cardiac diseases, and are also related to the type of cerebrovascular disease and its localization. We aimed to determine the pattern of ECG changes associated with pathophysiologic categories of acute stroke among patients with/without cardiovascular disease and to determine if specific ECG changes are related to the location of the lesion.

Materials and Methods

The electrocardiographic records of 361 patients with acute stroke were studied to assess the relative frequencies of ECG abnormalities among the pathophysiologic categories of stroke.

Results:

In the present study, the most common ECG abnormalities associated with stroke were T-wave abnormalities, prolonged QTc interval and arrhythmias, which were respectively found in 39.9%, 32.4%, and 27.1% of the stroke patients and 28.9%, 30.7%, and 16.2 of the patients with no primary cardiac disease. We observed that other ECG changes comprising pathologic Q- wave, ST-segment depression, ST-segment elevation, and prominent U wave may also occur in selected or non-selected stroke patients; thereby simulate an acute myocardial injury. We observed an increased number of patients with abnormal T-wave and posterior fossa bleedings and more rhythm disturbances for ischemic lesions, localized in the anterior fossa.

Conclusion:

Ischemia-like ECG changes and arrhythmias are frequently seen in stroke patients, even in those with no history or signs of primary heart disease, which support a central nervous system origin of these ECG abnormalities. Further study is necessary to better define the brain-heart interaction.

Hold the heparin

Dynamic ischemic-type electrocardiographic T-wave inversions raise the possibility of myocardial ischemia or infarction but are actually a nonspecific finding. We present a case of a young man presenting with headache and dizziness found to have marked hypertension, deepening T-wave inversions, and troponin elevation. Initial concerns were for acute coronary syndrome (ACS); however, before anticoagulant and antithrombotic therapy was instituted, further evaluation with noncontrast computed tomography of the head showed intraventricular hemorrhage. Electrocardiographic T-wave inversions are nonspecific and have a broad differential diagnosis, but ACS is of the highest concern especially in the setting of elevated troponin. However, as in this case, T-wave inversion and troponin elevation have been well described in intracranial bleeds as well, and full evaluation is required for such findings before initiation of therapy for presumed ACS to avoid a potentially catastrophic outcome.

T-wave inversion on electrocardiogram is related to the risk of acute coronary syndrome in the general population

BACKGROUND

T-wave inversion (TWI) is a frequently encountered electrocardiographic (ECG) finding during routine medical examination of asymptomatic individuals, and of patients with various clinical conditions. However, the role of isolated TWI in the prediction of acute coronary syndrome (ACS) in the community has not been extensively studied. We investigated the relationship between TWI in routine ECG and the risk for ACS in the general population.

METHODS

This study is based on a random sample of 1997 men aged 42-60 years in Eastern Finland. Electrocardiograms recorded at rest were classified using the Minnesota codes. The association between isolated TWI and ACS was determined using a multivariable adjusted Cox proportional hazard model.

RESULTS

Negative T-waves were present in 3.6% of the participants. During an average follow-up of 20 years, a total of 493 ACS events were registered. After adjusting for age, TWI was associated with a 3.10-fold (95% confidence interval (CI) 2.21-4.32) risk for ACS. After additional adjustment for previously known coronary risk factors, TWI remained statistically significant in predicting ACS (relative risk 2.23; 95% CI 1.57-3.15). Negative T-waves was one of the strongest risk markers for ACS compared with other ECG-based variables such as left ventricular hypertrophy, previous Q-wave and prolonged QRS duration.

CONCLUSION

TWI has a strong and independent predictive value for ACS in the general population.

Ischemic-appearing electrocardiographic changes predict myocardial injury in patients with intracerebral hemorrhage

OBJECTIVES

Myocardial injury is common among patients with intracerebral hemorrhage (ICH). However, it is challenging for emergency physicians to recognize acute myocardial injury in this population, as electrocardiographic (ECG) abnormalities are common in this setting. Our objective is to examine whether ischemic-appearing ECG changes predict subsequent myocardial injury in the context of ICH.

METHODS

Consecutive patients with primary ICH presenting to a single academic center were prospectively enrolled. Electrocardiograms were retrospectively reviewed by 3 independent readers. Anatomical areas of ischemia were defined as I and aVL; II, III, and aVF; V(1) to V(4); and V(5) and V(6). Medical record review identified myocardial injury, defined as troponin I or T elevation (cutoff 1.5 and 0.1 ng/mL, respectively), within 30 days.

RESULTS

Between 1998 and 2004, 218 patients presented directly to our emergency department and did not have a do-not-resuscitate/do-not-intubate order; arrival ECGs and troponin levels were available for 206 patients. Ischemic-appearing changes were noted in 41% of patients, and myocardial injury was noted in 12% of patients. Ischemic-appearing changes were more common in patients with subsequent injury (64% vs 37%; P = .02). After multivariable analysis controlling for age and cardiac risk factors, ischemic-appearing ECG changes independently predicted myocardial injury (odds ratio, 3.2; 95% confidence interval, 1.3-8.2). In an exploratory analysis, ischemic-appearing ECG changes in leads I and aVL as well as V(5) and V(6) were more specific for myocardial injury (P = .002 and P = .03, respectively).

CONCLUSION

In conclusion, although a range of ECG abnormalities can occur after ICH, the finding of ischemic-appearing changes in an anatomical distribution can help predict which patients are having true myocardial injury.

ECG change of acute subarachnoid hemorrhagic patients

OBJECTIVE

This study intends to investigate whether the entry electrocardiographic (ECG) abnormalities of patients with acute subarachnoid hemorrhage (SAH) are related to the prognosis.

METHODS

From 1998 to the present, 106 SAH patients who had no history of heart disease and were diagnosed with head CT were recruited.

RESULTS

Abnormal ECG changes of acute subarachnoid hemorrhage patients were observed, with a total incidence rate of 63.2% (67/106). The incidence rate of allorhythmia was 22.6% (24/106), the repolarization abnormality was 14.2% (15/106), the conduction abnormality was 1.9% (2/106), and the combined abnormality was 21.7% (23/106). However, dividing the patients into two groups according to their entry consciousness state, no difference was observed between coma and alert groups (P=1.0000). In addition, the ECG changes had no relationship with the lesion degree and the outcome prognosis according to logistic regression analysis (P=0.0844).

CONCLUSIONS

In 106 SAH patients, we could not identify any relationship between the ECG and lesion degree and outcome prognosis.

Electrocardiographic abnormalities in patients with intracerebral hemorrhage

BACKGROUND

Stroke is frequently followed by electrocardiographic changes. Although electrocardiographic abnormalities are well known in ischemic stroke and subarachnoid hemorrhage, these changes have only rarely been investigated systematically in patients with intracerebral hemorrhage. The purpose of this study is to investigate the prevalence and characterization of ECG abnormalities in a consecutive series of ICH patients who had no history of heart disease.

METHODS

The study was retrospective, and 304 intracerebral hemorrhage patients who met the study criteria were entered in the study. The ECG changes of the 304 acute hemorrhagic stroke patients without primary heart disease were analyzed. The relationship among the electrocardiographic abnormalities, the location of hematoma, and the clinical outcome were investigated to determine cardiac involvement in the cerebral hemorrhage in these patients.

RESULTS

A total of 304 patients were included. Two hundred and four patients (67.1%) had one or more ECG abnormalities. These changes included morphological waveform changes and arrhythmias, such as QTc prolongation, ST-T morphological changes, sinus bradycardia, inverted T wave, and conduction block. These ECG changes were not related to the level of the cerebral lesion, but were related to its location and the outcome.

CONCLUSIONS

Electrocardiographic abnormalities frequently occur after intracerebral hemorrhage, and these changes were not related to the level of the cerebral lesion, but were related to the location of the cerebral lesion and the outcome.