EKG Changes in Syncope due to Arrhythmia

Aka: EKG Changes in Syncope due to Arrhythmia, Electrocardiogram in Syncope

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II. Precautions

  1. Intervals and duration (PR Interval, QRS Duration, QTc Interval) are critical to evaluate in Syncope

III. Interpretation: EKG changes suggestive of Syncope due to Arrhythmia

  1. Abnormal Heart Rate
    1. Sinus Bradycardia <50 bpm (consider Sick Sinus Syndrome)
  2. Prolonged PR Interval
    1. Second Degree Atrioventricular Block
    2. Third Degree Atrioventricular Block
  3. Short PR Interval
    1. Wolff-Parkinson-White Syndrome
  4. Abnormal QRS
    1. Left Bundle Branch Block, anterior or posterior hemiblock or Bifascicular Heart Block
      1. Associated with a 3 fold higher risk of serious cardiac cause
    2. QRS Duration > 120 ms
    3. Q Waves
  5. Prolonged QTc Interval
    1. See QT Prolongation
    2. See Prolonged QT Interval due to Medication
    3. Long QT Syndrome

IV. Interpretation: EKG changes related to specific syndromes

  1. EKG in Acute Coronary Syndrome
    1. ST Segment Elevation (or ST depression in coronary ischemia)
    2. Deep T Wave Inversion
  2. EKG in Tachy-Brady Syndrome (Sick Sinus Syndrome)
    1. Tachycardia or Bradycardia
    2. Atrioventricular Block (especially Mobitz II or third degree AV Block)
  3. EKG changes seen in Wolff-Parkinson-White Syndrome (WPW Syndrome)
    1. Short PR Interval (<120 ms)
    2. Delta Waves
  4. EKG changes seen in Brugada Syndrome
    1. Right Bundle Branch Block (RSR')
    2. ST Elevation in leads V1-V3
  5. EKG in Arrhythmogenic Right Ventricular Dysplasia (ARVD)
    1. T Wave Inversion in leads V1-V3
    2. QRS Complex duration > 110 ms in leads V1-V3
    3. Right Bundle Branch Block
    4. Terminal notch at end of QRS (Epsilon Wave)
    5. Septal T Wave Inversion (V1-3)
  6. EKG in Hypertrophic Cardiomyopathy
    1. High voltage
    2. Lateral (esp. I, aVL, V4-6) and inferior Q Waves (deep, dagger or needle-like, narrow)
    3. Septal, deep, symmetric T inversion (variable)
  7. Abnormal QT Interval
    1. Prolonged QT Segment >500 ms
    2. Short QT Segment <300 ms
      1. Autosomal Dominant condition associated with Sudden Cardiac Death
  8. EKG with right ventricular strain pattern (e.g. Pulmonary Embolism)
    1. See Right Ventricular Strain EKG Pattern
    2. Right Bundle Branch Block
    3. T Wave Inversion in anterior (V1-3) or inferior (II, III, avF) leads
    4. Prominent P Waves
    5. S1-Q3-T3 Pattern (S in I, Q in III, T inversion in III)
  9. EKG in Hyperkalemia
    1. Initial: Peaked T Waves in V2-3, II, III
    2. Next: ST depression, First degree AV Block, QT Interval shortening
    3. Next: QRS Widening with loss of P Waves
  10. EKG in Increased Intracranial Pressure
    1. Very large amplitude T Waves
    2. Prolonged QT
  11. EKG in Atrial Septal Defect (ASD, Ostium Secundum)
    1. Crochetage sign (correlates with severity of left to right shunt)
    2. Right Bundle Branch Block

V. Efficacy

  1. EKG is low yield in syncopal patients under age 40 years old (however most warrant EKG in ED evaluation)
    1. Sun (2008) Ann Emerg Med 51(3): 240-6 [PubMed]

VI. References

  1. Mattu in Herbert (2014) EM:Rap 14(7): 15-6
  2. Brignole (2001) Eur Heart J 22:1256-306 [PubMed]

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Related Studies

Ontology: Syncope (C0039070)

Definition (MEDLINEPLUS)

Fainting is a temporary loss of consciousness. If you're about to faint, you'll feel dizzy, lightheaded, or nauseous. Your field of vision may "white out" or "black out." Your skin may be cold and clammy. You lose muscle control at the same time, and may fall down.

Fainting usually happens when your blood pressure drops suddenly, causing a decrease in blood flow to your brain. It is more common in older people. Some causes of fainting include

  • Heat or dehydration
  • Emotional distress
  • Standing up too quickly
  • Certain medicines
  • Drop in blood sugar
  • Heart problems

When someone faints, make sure that the airway is clear and check for breathing. The person should stay lying down for 10-15 minutes. Most people recover completely. Fainting is usually nothing to worry about, but it can sometimes be a sign of a serious problem. If you faint, it's important to see your health care provider and find out why it happened.

Definition (NCI) A spontaneous loss of consciousness caused by insufficient blood supply to the brain.
Definition (NCI_CTCAE) A disorder characterized by spontaneous loss of consciousness caused by insufficient blood supply to the brain.
Definition (NCI_FDA) Extremely weak; threatened with syncope.
Definition (NCI_CDISC) Sudden loss of consciousness with loss of postural tone, not related to anesthesia, with spontaneous recovery as reported by patient or observer. A subject may experience syncope when supine. Syncope is often caused by insufficient blood supply to the brain.
Definition (NCI) Extremely weak; threatened with syncope.
Definition (MSH) A transient loss of consciousness and postural tone caused by diminished blood flow to the brain (i.e., BRAIN ISCHEMIA). Presyncope refers to the sensation of lightheadedness and loss of strength that precedes a syncopal event or accompanies an incomplete syncope. (From Adams et al., Principles of Neurology, 6th ed, pp367-9)
Definition (CSP) fainting due to a sudden fall of blood pressure below the level required to maintain oxygenation of brain tissue.
Concepts Sign or Symptom (T184)
MSH D013575
ICD9 780.2
ICD10 R55
SnomedCT 206727002, 206725005, 206731008, 271594007, 271211004, 29423006, 158137001, 158135009, 271785004, 158133002, 139532000, 162263008, 309585006, 272030005
LNC MTHU020851, LA16987-2
English Fainting, Syncope, Syncopes, COLLAPSE TRANSIENT, FAINTNESS, FALLING OUT, Fainted, PASSED OUT, SWOONING, Syncope and collapse NOS, [D]Syncope, [D]Syncope and collapse, [D]Syncope and collapse NOS, A faint, Passed out, [D]Fainting (context-dependent category), [D]Syncope and collapse (context-dependent category), [D]Syncope and collapse NOS (context-dependent category), [D]Fainting, fainting (syncope), syncope, fainting, fainting (symptom), Syncopal attack, Falling out, Swooning, Faint, Syncope [Disease/Finding], attacks syncopal, disorders syncope, fainting episodes, falls out, Attack(s);fainting, collapse syncope, faint, fainted, faints, syncope attack, out pass, pass out, attacks fainting, out passed, syncopes, fainting/syncope, Swoon, syncope fainting, faintness, swoons, out passes, swooning, passed out, syncope collapse, fainting syncope, [D]: [fainting] or [collapse] (disorder), [D]Syncope and collapse NOS (situation), Syncope (finding), [D]: [fainting] or [collapse] (situation), [D]Syncope and collapse (situation), [D]Fainting (situation), Fainting (finding), Fainting [D], Faint symptom, [D]: [fainting] or [collapse], SYNCOPE, FAINT, FAINTING, Syncope and collapse, Syncope symptom, Syncope attack, Syncope (disorder), Syncope and collapse (disorder), Syncope symptom (disorder), Fainting/syncope, attack; syncope, attack; unconsciousness, collapse; general, fainting; fit, fit; fainting, general; collapse, loss of consciousness; attack, syncope; syncope, unconsciousness; attack, Syncope, NOS, Faintness, Collapse fleeting, Collapse transient, fainting attacks, swoon
French SYNCOPE, Collapsus passager, Tendance lipothymique, Syncope et collapsus, Evanouissements, Collapsus transitoire, Chutes fréquentes, Pâmoison, Lipothymie, COLLAPSUS TRANSITOIRE, DECES, ETAT SYNCOPAL, EVANOUISSEMENT, PERTE DE CONNAISSANCE, A perdu connaissance, Syncope, Évanouissement
Portuguese SINCOPE, DESMAIO, Síncope e colapso, Ataque de síncope, Colapso transitório, Esvaimento, Perda de consciência, Desmaiado, Colapso passageiro, COLAPSO TRANSITORIO, DEBILIDADE, DESFALECIMENTO, DESMAIADO, Desmaio, Síncope
Spanish DESVANECIMIENTO, SINCOPE, DESMAYO, Colapso transitorio, Desfallecimiento, Episodio sincopal, Síncope y colapso, Privación de sentido, Alferecía, Pérdida de conocimiento, Desvanecimiento, Colapso fugaz, [D]desvanecimiento (categoría dependiente del contexto), [D]síncope y colapso (categoría dependiente del contexto), [D]síncope y colapso SAI (categoría dependiente del contexto), CAIDA, COLAPSO TRANSITORIO, DESFALLECIMIENTO, desvanecimiento, desvanecimiento (hallazgo), [D]síncope y colapso SAI, [D]desvanecimiento (situación), síncope (hallazgo), [D]síncope y colapso SAI (situación), [D]síncope y colapso (situación), [D]desvanecimiento, [D]síncope y colapso, desmayo, síncope (trastorno), síncope - síntoma (trastorno), síncope - síntoma, síncope y colapso (trastorno), síncope y colapso, síncope, Desmayo, Síncope
German SYNKOPE, ohnmaechtig, Kollaps fluechtig, synkopale Attacke, bewusstlos werden, Synkope und Kollaps, Kollaps voruebergehend, schwummrig, ohnmaechtig werden, Ohnmachtsanfall, BEWUSSTLOSIGKEIT FLUECHTIG, KOLLAPS KURZDAUERND, OHNMACHT, OHNMAECHTIG WERDEN, SCHWAECHEANFALL, Ohnmacht, Synkope
Dutch kortdurende collaps, flauwte, flauw, flauwteaanval, flauwvallen, voorbijgaande collaps, syncope en collaps, uitvallen, flauwgevallen, aanval van syncope, Flauwvallen/syncope, aanval; bewusteloosheid, aanval; syncope, algemeen; collaps, bewusteloosheid; aanval, bewustzijnsverlies; aanval, collaps; algemeen, flauwvallen; toeval, syncope; aanval, toeval; flauwvallen, Syncope en collaps, syncope, Collaps, Flauwvallen, Syncope
Italian Attacco sincopale, Sfaldarsi, Sincope e collasso, Collasso transitorio, Malore, Svenuto, Svenimento, Sincope
Japanese 卒倒, 一過性虚脱, 浮動性めまい感, 失神発作, ｼｯｼﾝ, ｲｯｶｾｲｷｮﾀﾞﾂ, ｿｯﾄｳ, ｼｯｼﾝﾎｯｻ, ﾌﾄﾞｳｾｲﾒﾏｲｶﾝ, ｷｾﾞﾂ, 脳貧血, 気絶, 失神
Swedish Svimning
Czech synkopa, Tranzientní kolaps, Synkopický záchvat, Omdlívající, Mdloba, Synkopa a kolaps, Synkopa, Výpadek, Upadnout do bezvědomí, Pocit závratě, mdloba
Finnish Pyörtyminen
Russian SINKOPE, OBMOROK, OBMOROK POSTURAL'NYI, POTERIA SOZNANIIA, PREDOBMOROCHNOE SOSTOIANIE, ОБМОРОК, ПОТЕРЯ СОЗНАНИЯ, ОБМОРОК ПОСТУРАЛЬНЫЙ, ПРЕДОБМОРОЧНОЕ СОСТОЯНИЕ, СИНКОПЕ
Korean 실신 및 허탈
Croatian SINKOPA
Polish Zapaść, Omdlenie
Hungarian Ájult, Syncopés roham, Syncope és collapsus, Átmeneti collapsus, Ájulásérzés, Múló collapsus, Syncope, Ájulás, Elájulás, Összeesés
Norwegian Synkope, Besvimelse
Derived from the NIH UMLS (Unified Medical Language System)

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