A Decade of ECG Gems: The Final 5 Favorite Cases

Top 5 Cases of the Decade

Case #5: Brugada Hiding in Between NSVT Runs (December 17, 2018)

• Presentation: A 50-year-old with palpitations, low-grade fever, and runs of nonsustained ventricular tachycardia (NSVT).
• Surprise Finding: On close inspection of the beats between the NSVT runs, the patient has Brugada Syndrome (characteristic coved ST elevations in V1–V2).
• Take-Home Points: 
  • Avoid Sodium Channel Blockers (e.g., procainamide, amiodarone) in suspected Brugada to prevent malignant arrhythmias.
  • Always inspect the “quiet” parts of the ECG; the biggest clue might lie in seemingly unremarkable beats. Be thorough in your evaluation. 

Case #4:  Potential Side Effect of Adenosine 

1. May 20, 2024 – SVT Treated with Adenosine → AF + WPW
   • Patient developed rapid atrial fibrillation with WPW conduction after receiving adenosine for presumed SVT.
   • Key Point: Adenosine can unmask or induce AF in patients with undiagnosed WPW, necessitating prompt cardioversion if unstable.
2. December 6, 2021 – Pregnant Patient with SVT → AF + WPW
   • Similarly, a 25-year-old at 39 weeks gestation received adenosine for SVT and developed AF with WPW.
   • Take-Home Points: 
     • No antiarrhythmic is entirely “safe”!
     • Adenosine may trigger AF, which becomes dangerous if underlying WPW is present. Adenosine has been reported to cause SVT to turn into AF in up to 12% of cases. 
     • Be prepared to cardiovert when using any antiarrhythmic; always have defibrillation on standby.

Case #3: Spiked Helmet Sign (December 21, 2015)

• Presentation: A 64-year-old with chest pain radiating to the neck, neurologic symptoms, and a bizarre-looking QRS complex in V2 that resembled a spiked helmet.
• Outcome: The patient arrested (PEA) shortly thereafter.
• Take-Home Points: 
  • This unusual spiked helmet sign on ECG is consistently associated with critical illness and high risk of imminent cardiac arrest—an alarm for expedited diagnosis and intervention.
  • Cause of the morphology is uncertain, upward shift of the baseline begins prior to the QRS complex.
  • Suggests intra-abdominal pathology if present in limb leads. Suggests intra-thoracic pathology if present in the precordial leads. 

Case #2: T-Wave Alternans in a Pediatric Patient (December 30, 2019)

• Presentation: An infant with persistent GI illness and an ECG demonstrating long QT and T-wave alternans (amplitude changes in consecutive T-waves).
• Take-Home Points: 
  • T-wave alternans (beat to beat variation in size or shape of the T wave) is a red flag for impending Torsades de Pointes or other malignant arrhythmias.
  • Recognize it promptly, treat the underlying cause, and administer IV magnesium as indicated.

Case #1: Atrial Parasystole (August 2, 2021)

• Presentation: A 17-year-old with stable palpitations and an ECG revealing two distinct P-wave morphologies, each pacing the atria independently.
• Significance:
  • Atrial parasystole is rare in routine practice but is a fascinating example of two atrial foci firing concurrently with no mutual suppression.
  • Underlines the importance of carefully examining P-wave morphology and regularity.

Final Thoughts & Honorable Mentions

• Other noteworthy, “honorable mention” cases from the past decade include: Hypercalcemia mimicking STEMI, Lewis lead, pulse-tapping artifact, crochetage pattern, isorhythmic AV dissociation, and intermittent hidden WPW.
• Message of Thanks: Dr. Mattu expresses gratitude for the community’s involvement and looks forward to another decade of amazing case submissions and ECG discoveries.