EMS is called to evaluate an unconscious 37 year old male.
En route to the scene dispatch advises paramedics that the patient is now conscious and may have experienced a syncopal episode and seizure-like activity. The spouse believes that the patient may be having a stroke.
On arrival the patient is found lying in bed. He is alert and oriented to person, place and time, but not event.
He appears to be in excellent shape.
The spouse informs the EMS crew that the patient is an endurance athlete who has recently undergone chelation therapy to “clean out his system.” It’s clear this has been a controversial topic their relationship. The spouse is not pleased about it.
She is clearly shaken by what has happened and is particularly concerned that the patient slurred his speech immediately after re-gaining consciousness.
The patient states that he was “worked up for chest pain” about 3 months ago and all tests came back negative. Otherwise he states that he has been healthy. He takes no meds.
Vital signs are assessed.
- RR: 18
- HR: 80 R
- BP: 140/90
- SpO2: 98% on room air
- BGL: 108
Breath sounds are clear bilaterally.
The cardiac monitor is attached.
A 12-lead ECG is captured.
The paramedics sit the patient up to check orthostatics. The patient’s eye contact becomes less focused and his speech becomes slurred. He seems weak.
What are your concerns? Is this a normal ECG for an endurance athlete?
There are a few difficulties involved with this case.
First, we have the syncopal episode with possible seizure-like activity and slurred speech.
Second, we have an abormal ECG.
Third, there is a recent history of chelation therapy which may or may not be playing a role in what’s happening.
For any patient who experiences a syncopal episode the ECG should be reviewed for cardiac arrhythmias, ischemia, long or short QT interval, Brugada, ARVD, WPW, and hypertrophic cardiomyopathy.
In the endurance athlete it can be difficult to distinguish between an “athlete’s heart” and hypertrophic cardiomyopathy without the aid of an echocardiogram to examine the exact dimensions and shape of the left ventricle.
To me, this ECG shows atypical left ventricular hypertrophy with a “strain pattern” (or secondary ST-T wave abnormality).
Consider the following graphics.
Leads V1 and V2 show an unusual rSr’ pattern. ST-elevation is present and the degree of ST-elevation appears to be proportional to the depth of the S-wave. Note that the S-wave is “cropped” in lead V3 by the bottom of the ECG graph paper.
Now let’s look at the lateral leads.
Here again we see “T-wave discordance”. In other words, the T-waves are deflected opposite the main deflection of the QRS complex. In addition, the degree of the ST-T wave abnormality is proportional to the size of the QRS complex.
Finally, take a look at the T-waves in the precordial leads.
As the QRS complexes transition from negative to positive in leads V1-V6 the T-waves transition from positive to negative.
If you look at the QRS and T axis at the top of the ECG the QRS axis is 43 and the T axis is 144 which makes the QRS/T angle 101. When the QRS/T angle is ≥ 100 it’s a mathematical representation that, generally speaking, the T-waves are deflected opposite the majority of the QRS complex.
So it’s clear we’re dealing with left ventricular hypertrophy and a strain pattern.
Is it “normal” for an endurance athlete?
The patient ended up receiving a CT scan of the head at the receiving hospital. A slow venous bleed was discovered. He was transferred to a tertiary care center for more advanced care. The ED physician did not seem particularly concerned about the 12-lead ECG.
Does that mean it was normal for him?
Here’s what electrophysiologist and cyclist Dr. John M had to say:
That ECG is very abnormal. Agree with strain diagnosis. Not only that, but the QRS is notched and fragmented. V1’s pattern along with the prominent p-wave voltage suggests the possibility of an ASD. I would agree with you entirely about the non-benignness of this patient’s syncope, and I would be very interested in the ECHO report.
The best thing the EMS crew did for this patient was take him to the hospital.
Electrocardiographic interpretation in athletes: the ‘Seattle Criteria’ (PDF)