"Lambda-wave" ST-elevation is associated with severe prognosis in stress (takotsubo) cardiomyopathy

Shark fin sign: A rare EKG finding in a patient with Takotsubo cardiomyopathy from influenza A infection

This case demonstrated the rare "shark fin" ECG pattern, an ST-segment elevation typically seen in acute myocardial infarction. We reported a case of takotsubo cardiomyopathy secondary to influenza A infection with multiple organ failure, showing the shark fin sign and resulting in in-patient mortality and various complication.

The Critical Role of Lambda-Shaped QRS-ST-T Wave Fusion ST-Elevation in Diagnosing and Managing Takotsubo Cardiomyopathy: A Case Report and Review of Literature

Stress-induced cardiomyopathy, commonly known as Takotsubo cardiomyopathy (TCM), is a clinical syndrome characterized by acute and transient ventricular systolic dysfunction that often presents with chest pain and may resemble an acute coronary syndrome. This case report discusses a complex clinical scenario involving an adult female with severe depression who attempted suicide through drug overdose, subsequently developing serotonin syndrome. Her clinical presentation was further complicated by the emergence of a unique lambda-shaped triangular QRS-ST-T waveform fusion ST-elevation electrocardiographic (ECG) pattern closely mimicking an anterolateral occlusive myocardial infarction. The study delves into the clinical implications of this unique ECG pattern in TCM, providing valuable insights into diagnosing and treating such complex cases. This case underscores the importance of recognizing diverse manifestations of TCM and its potential for severe cardiovascular complications.

Spiked Helmet Sign: An Uncommon Electrocardiographic Marker

The spiked helmet sign (SHS) is a rare electrocardiographic marker associated with an increased risk of lethal ventricular tachyarrhythmias and sudden cardiac death. To our knowledge, this is the first study aimed at reviewing recent research progress on this electrocardiogram (ECG) pattern to summarize its electrophysiological mechanisms, epidemiological features, clinical characteristics, and clinical significance. SHS formation is attributed to sympathetic hyperactivity, which mediates increased dispersion of ventricular repolarization, leading to marked QT prolongation and macroscopic T-wave alternans. This pattern can be observed in critically ill patients with cardiac or noncardiac conditions. In particular, immediate identification of this ECG abnormality is crucial in recognizing and treating noncardiac conditions in older male patients.

Shark Fin Occlusive Myocardial Infarction ECG Pattern Post-cardiac Arrest Misinterpreted As Ventricular Tachycardia

In addition to the well-known convex ST-segment elevation myocardial infarction (STEMI) pattern associated with acute occlusive myocardial infarction (OMI), there are other cases that are recognized as OMI without fulfilling the established characteristic STEMI criteria. Over one-fourth of the patients initially classified as having non-STEMI can be re-classified as having OMI by recognizing other STEMI equivalent patterns. We report a case of a 79-year-old man with multiple comorbidities who was brought to the ED by paramedics with a two-hour history of ongoing chest pain. During transport, the patient suffered a cardiac arrest associated with ventricular fibrillation (VF) that required electric defibrillation and active cardiopulmonary resuscitation. Upon ED arrival, the patient was unresponsive, with a heart rate of 150 beats/min and ECG evidence of wide-QRS tachycardia that was misinterpreted as ventricular tachycardia (VT). He was further managed with intravenous amiodarone, mechanical ventilation, sedation, and unsuccessful defibrillation therapy. Upon persistence of the wide-QRS tachycardia and clinical instability, the cardiology team was emergently consulted for bedside assistance. On further review of the ECG, a shark fin (SF) OMI pattern was identified, indicative of an extensive anterolateral OMI. A bedside echocardiogram revealed a severe left ventricular systolic dysfunction with marked anterolateral and apical akinesia. The patient underwent a successful percutaneous coronary intervention (PCI) to an ostial left anterior descending (LAD) culprit occlusion with hemodynamic support but ultimately died due to multiorgan failure and refractory ventricular arrhythmias. This case illustrates an infrequent OMI presentation (<1.5%) formed by the fusion of the QRS, ST-segment elevation, and T-wave resulting in a wide triangular waveform, giving the appearance of an SF that can also potentially lead to ECG misinterpretation as VT. It also highlights the importance of recognizing STEMI-equivalent ECG patterns to avoid delays in reperfusion therapy. The SF OMI pattern has also been associated with a large amount of ischemic myocardium (such as with left main or proximal LAD occlusion) with a higher mortality risk from cardiogenic shock and/or VF. This high-risk OMI pattern should lead to a more definite reperfusion treatment, such as primary PCI and the possible need for backup hemodynamic support.

SHARK FIN ECG PATTERN IN A PATIENT WITH TAKOTSUBO SYNDROME - CASE STUDY AND LITERATURE REVIEW

Shark fin or triangular QRS-ST-T waveform ECG pattern, also known as lambda-wave ST elevation or giant R wave syndrome, is a particular ECG presentation where QRS complex, ST-segment and T-wave are fused in a unique complex. Originally described in some patients with ST-segment elevation myocardial infarction (STEMI) during the acute phase, it has been found to be associated with a high risk of ventricular fibrillation and cardiogenic shock as well as with a high in-hospital mortality. However, shark fin ECG pattern has also been reported in patients with non-acute coronary syndrome related ST-elevation (NASTEP), including stress-induced takotsubo syndrome (TTS). Fourteen such cases (all females) have been reported so far. The authors present a case of a 56-year-old male with shark fin ECG pattern associated with TTS triggered by burn injuries of head, back, upper, lower limbs and the respiratory tract. Due to respiratory insufficiency and heart failure with hemodynamic compromise, he required mechanical ventilation and catecholamines use. Echocardiography showed apical and midventricular akinesia with left ventricular ejection fraction and global longitudinal strain reduced to 30% and -6.8%, respectively and a high segmental post-systolic index. Shark fin pattern maintained within 2 days, then ST-T evolution was observed. Echocardiographic improvement followed by almost normalization were seen after 6 and 9 days, respectively. No cardiac arrhythmias were recorded as in most of the described cases with shark fin ECG and TTS.

Association between Tpeak-Tend/QT and major adverse cardiovascular events in patients with Takotsubo syndrome

BACKGROUND

Conflicting results have been described in the scientific literature regarding the relationship between electrocardiographic parameters and complications in patients with Takotsubo syndrome (TTS). Aim of the present study was to investigate whether there is an association between markers of ventricular repolarization and major adverse cardiovascular events (MACE) during hospitalisation.

METHODS

A retrospective chart review was conducted on a sample of patients with diagnosis of TTS, based on the fulfilment of the revised Mayo Clinic criteria. MACE included acute heart failure, cardiogenic shock, sustained ventricular tachycardia, ventricular fibrillation, and death. The following parameters, assessed on the admission electrocardiogram, were analysed: ST-segment elevation, ST-segment depression, T wave inversion, presence of Q waves, QT interval, QT interval corrected for heart rate, QT-dispersion, Tpeak-Tend (Tpe) interval, Tpe dispersion, Tpe/QT ratio, and QTpeak/QT ratio.

RESULTS

Patients with MACE, compared to patients without MACE, showed more commonly anterior ST-segment elevation and had significantly higher values of Tpe/QT ratio. Low ejection fraction and Tpe/QT ratio > 0.27 identified a sub-population of patients more likely to have MACE during hospitalisation.

CONCLUSIONS

Tpe/QT ratio represents a useful electrocardiographic parameter in the acute phase of TTS.

A 'shark'-masked electrocardiogram: case report of a Tako-Tsubo syndrome

Background

Triangular ST-segment elevation or 'shark-fin' sign has been described as a specific indicator of acute coronary occlusion and large myocardial ischaemia, translating into poorer prognosis. However, this electrocardiographic presentation has been reported in rare cases of Tako-Tsubo syndrome and associated with more severe physical stressors and neurological involvement.

Case summary

We present a rare case of a 51-year-old woman presenting with incoming epileptic attacks and concomitant pyometra. Despite controlling epilepsy with phenytoin and the surgical treatment of the infection, she developed sepsis requiring vasopressors, and thereafter sustained ventricular tachycardia and diffuse ST-segment elevation with the 'shark-fin' sign. TTC was confirmed by the documentation of normal coronary arteries and the complete recovery of wall motion abnormalities at discharge.

Discussion

Heterogeneous presentation and triggering conditions often challenge the diagnosis of Tako-Tsubo syndrome. The acknowledgement of different electrocardiographic and clinical manifestations can ease the diagnosis and the successful management of these patients, whose prognosis can be extremely severe in the acute phase, if unidentified.

Electrocardiographic changes in Takotsubo cardiomyopathy

Takotsubo Cardiomyopathy (TC) is a syndrome characterized by reversible left ventricular dysfunction in the presence of possible emotional or physical triggers but without evidence of obstructive coronary artery disease. It has become increasingly reported worldwide and is associated with significant morbidity and mortality. TC may present with an array of electrocardiographic (ECG) findings. These ECG findings, if accurately interpreted, can play an important role in the diagnosis and risk stratification of this syndrome. In the last three decades since the disease was first described, multiple diagnostic criteria have been established. The key diagnostic tools for TC include clinical symptomatology, cardiac biomarkers, non-invasive cardiac imaging, and coronary angiography. The ECG findings in TC can be variable, however, some ECG scores have been proposed in association with TC with reasonably good diagnostic sensitivity and specificity. This article aims to provide a succinct review of important electrocardiographic findings associated with TC and its impact on clinical outcomes.

[Clinical Manifestation of Stressful Cardiomyopathy (Takotsubo Syndrome) and the Problem of Differential Diagnosis with Acute Myocardial Infarction]

The presented data show that tacotsubo syndrome (TS) is characterized by the absence of coronary artery obstruction, cardiac contractile dysfunction, apical ballooning, and heart failure, and in some patients, ST-segment elevation and prolongation of the QTc interval. Every tenth patient with TS develops ventricular arrhythmias. Most of TS patients have elevated markers of necrosis (troponin I, troponin Т, and creatine kinase МВ (CK-МВ), which are considerably lower than in patients with acute myocardial infarction (AMI) with ST-segment elevation. The level of N-terminal pro-B-type natriuretic peptide (NT-proBNP), in contrast, is considerably higher in patients with TS than with AMI. Differential diagnosis of TS and AMI should be based on a multifaceted approach using coronary angiography, echocardiography, analysis of ECG, magnetic resonance imaging, single-photon emission computed tomography, and measurement of troponins, CK-MB, and NT-proBNP.

Triangular QRS-ST-T Waveform Electrocardiographic Pattern in Acute Myopericarditis: A Case Report from a Limited-Resources Hospital

BACKGROUND Triangular QRS-ST-T waveform (TW) electrocardiography pattern has been found to be associated with poor prognosis in patients with ST-segment elevation myocardial infarction (STEMI). It identifies a subset of patients at high risk of both ventricular fibrillation and cardiogenic shock, with high in-hospital mortality. Therefore, aggressive treatment is needed in patients presenting with this electrocardiography pattern. However, this pattern is rarely present in non-ischemic cardiac diseases. CASE REPORT We report the case of a 50-year-old man who came to our emergency room with a chief complaint of gastrointestinal problems and partial bowel obstruction. After failure of initial conservative treatment, laparotomy was planned. Just before the surgery, the patient felt a non-specific chest discomfort and showed ST-segment elevation on ECG and slight elevation of cardiac enzyme. He was then treated for STEMI with an intravenous thrombolytic. However, the degree of ST-segment elevation further increased and showed a TW pattern. Transthoracic echocardiography revealed a moderate pericardial effusion with normal ejection fraction and a normokinetic left ventricle; hence, a diagnosis of acute myopericarditis was made. After treatment with low-dose steroid and colchicine, his symptoms improved, the electrocardiography pattern returned to normal, and the gastrointestinal symptoms resolved. CONCLUSIONS To the best of our knowledge, this is the first case report of an acute myopericarditis presenting with a TW electrocardiography pattern. Myopericarditis should always be considered in the differential diagnosis of acute chest pain and ST segment electrocardiography changes, including TW pattern. The use of echocardiography can help determine the diagnosis of myopericarditis.

The electrocardiographic 'triangular QRS-ST-T waveform' pattern: a marker of severe haemodynamic compromise in Takotsubo syndrome-a case report

Background

Takotsubo cardiomyopathy is characterized by transient regional systolic dysfunction of the left ventricle, mimicking myocardial infarction. Although systolic left ventricular (LV) function normalizes in most cases, the outcome is not always favourable. Recently, a rare electrocardiogram (ECG) finding, lambda wave ST elevation or 'triangular QRS-ST-T waveform', was suggested as a possible marker of poor outcome in Takotsubo patients.

Case summary

After a brief episode of chest pain and shortness of breath, a 67-year-old woman developed cardiogenic shock. Her resting ECG showed widespread ST elevations, which soon evolved into a pattern of triangular QRS-ST-T waveforms in the inferior leads and V3-V6. Emergent coronary angiography was normal. The ejection fraction was 20% with apical ballooning and an LV thrombus. At 1-month follow-up, the patient was asymptomatic and the ECG showed only T-wave inversions.

Discussion

The triangular QRS-ST-T waveform ECG pattern has recently been introduced as a high-risk marker in the Takotsubo syndrome.

Lambda-like J wave due to acute myocardial infarction of the diagonal branch

The culprit lesion of acute myocardial infarction could be predicted by electrocardiogram findings. However, we experienced some cases with coronary angiographic finding in the area of ST-T elevation that was different from that predicted. The lambda-like J wave could be caused by ischemia although the mechanism has not been fully elucidated. We report a case of acute myocardial infarction that showed discrepancy between ST-T elevation with lambda-like ischemic J wave in a broad area and coronary angiographical finding of diagonal branch occlusion. J. Med. Invest. 66 : 185-187, February, 2019.

"Lambda-wave" ST-elevation is associated with severe prognosis in stress (takotsubo) cardiomyopathy

BACKGROUND

Persistent ST-segment elevation in acute coronary syndrome is associated with both short and long-term complications. By contrast, there is limited information about ST-elevation and its evolution during takotsubo (stress) cardiomyopathy (TTC).

AIM

To evaluate whether persistent downsloping ST-elevation in the early stages of TTC might correlate with short and long-term clinical events.

METHODS

One-hundred fifty-eight consecutive subjects with TTC were prospectively enrolled and assessed by electrocardiogram. Patients were classified in two groups according to the presence of downsloping ST-elevation ≥5 mm lasting at least 24 hr ("lambda-wave" ST-elevation group vs. without downsloping ST-elevation) in at least one/two contiguous leads.

RESULTS

Five (3.2%) patients, all female with a mean left ventricular ejection fraction 32 ± 5%, were included in the lambda-wave ST-elevation group. These patients were characterized by a higher prevalence of physical stressor (100% vs. 49%, p = 0.04) and higher admission and peak levels of troponin-I levels during hospitalization. Peak of ST-elevation in the lambda-wave ST-elevation group was reached 6 hr after admission and gradually decreased after 24 hr. In-hospital complications were observed in all the patients presenting lambda ST-elevation (100% vs. 23%, p = 0.03, OR: 29.1, p = 0.04); one patient presented endoventricular thrombosis and two died of cardiogenic shock. At long-term follow-up (mean 443 days), adverse events were observed in 80% of patients with lambda-wave ST-elevation (RR of adverse events at follow-up 32, p < 0.01).

CONCLUSION

Persistent downsloping lambda-wave ST-elevation during the acute phase of stress cardiomyopathy may be associated with a higher risk of adverse events at short and long-term follow-up.