Monday, December 29, 2014

EKG Challenge No. 7: Young Lady Swooning?

A 22-year-old female with no past medical history presents to the Emergency Department after a syncopal episode at home. She reports feeling lightheaded and then noticed her heart was pounding, prior to passing out. Her mother caught her, and she came to in "about a minute." She was brought to the ED by EMS. On further history, she stated she had not eaten anything today and had just gotten back from a jog outside when she began to feel lightheaded. She had a few similar episodes in the past when she has had blood drawn. Now she feels slightly weak but otherwise back to normal. Fingerstick glucose is normal, as well as CBC, BMP, and U/A. Her pregnancy test is negative. Her EKG is below.

What is your next step?  Please share your thoughts.

Read the Case Conclusion  here


  1. ?Brugada syndrome.

  2. I see a NSR with high voltage that is likely normal for this patient and does not represent any underlying pathology. There is also two non-conducted p waves with i believe a compensatory pause. I would consider the t wave inversion in V1 to be a persistent juvenile t wave pattern but, would also do a few tests to rule out PE. Since the patient had similar cases when having blood drawn I would consider it vasovagal and not arrhythmogenic.

  3. I'm guessing HCM given that it meets LVH criteria which seems to be more anterior. There are also non-specific ST changes, though it lacks the deep narrow Q waves that are often described with this condition. In general I was always taught to look for the following 4 abnormalities in the ECG of young syncopating patients: 1) WPW, 2) Long QT, 3) Brugada, 4) HCM

  4. I thought Brugada syndrome too...

  5. I agree with Joan. In this patient with LVH criteria and symptom onset during physical exertion I would be worried about HOCM. A quick bedside cardiac ultrasound showing significant LVH in this otherwise young/healthy person can help make the diagnosis.

  6. This EKG challenge was very frustrating to me since I couldn't really figure it out. Exertional syncope is certainly worrisome and should not be taken lightly, as any LVOT obstruction should be considered: HCM and aortic stenosis, also tachydysrhythmias, Brugada, pre-excitation. However, post-exertional syncope, which is what this lady actually had, is usually benign related to vasodilation and often dysautonomia combined with dehydration. That is, as you stop running/exercising, your muscles are no longer squeezing your veins, so you get venous pooling in your legs which diminishes preload, and combined some arterial vasodilation diminishes cerebral perfusion. That's why people collapse a lot of times after they cross the finish line and come to an abrupt stop (happened to me in high school).
    Amal Mattu suggests ruling out 7 bad diagnoses with every EKG after syncope: 1) ACS, 2) WPW, 3) Brugada, 4) HCM or LVH in young person, 5) Long QT and even short QT, 6) arrhythmias: SVT, AFib, heart block, etc., and 7) arrhythmogenic RV dysplasia.
    This EKG at first glance appears mostly normal, so I took a closer look. Regular rate, normal axis, appears to be sinus but actually irregular R-R interval, but QRS complex after every P wave, other intervals appear normal: PR, QT, QRS, ST segments normal except for humped T waves in V2, V3.
    At first glance, there appears to be increased voltage concerning for LVH, but when I looked up all the formulas to calculate LVH, she doesn't fit any criteria for LVH; comes close, but doesn't fit (one formula I found however states any R plus any S wave in precordial leads >40 is LVH but everywhere else it must be >45 mm. She has 41-43 mm maximum I believe. Also, there aren't the deep Q waves or deep inverted T waves seen with HOCM.
    What to do with that camel hump T wave? It's too sharp to be a U wave, plus BMP is normal. It's not another P wave since you don't see it in V1, or any other lead for that matter. I guess it could be a non-conducted PAC that is hidden within the T wave of V1. What has weird T waves? Brugada does but there's no ST elevation or even J-point elevation here so that's out. Wellen's syndrome is typically biphasic positive and sharp decline to negative T-wave, and this lady seems too young to have coronary occlusion.
    So, we have sinus arrhythmia, concerning voltage for LVH in young person but not meeting criteria exactly, no signs of ischemia or tachydysrhythmias, and post-exertional syncope, and a camel hump T-wave, normal electrolytes, no anemia, not pregnant. I would do what Joan and Kristen said. Put an ultrasound probe on heart to look for LV hypertrophy or formal echocardiogram. But I don't think it's type 2 or type 3 Brugada. Also TWI in V1 is normal. Maybe it's just non-conducted PAC that only occurred twice in V2/V3 and was hidden in T wave of V1.

    Everybody that's saying LVH, what criteria are you using to determine that (other than just seeing big R and S waves)?