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May 2, 2023
DRUGS ALTERING
ECGDr. AMREEN SABA ATTARIYA
POST GRADUATE STUDENTDEPT OF PHARMACOLOGY
M.R. MEDICAL COLLEGE, GULBARGA INDIA
Dr.ASA:DrugsAlteringECG
OverviewItroductionConduction Pathways Systematic InterpretationDrugs altering ECGSummaryReferences
May 2, 2023Dr.ASA:DrugsAlteringECG
IntroductionNumerous toxins and drugs that can cause, in overdose, electrocardiogram (ECG) changes.
Abnormal ECG encountered in a specific toxicity can challenge experienced physicians.
Need for serious knowledge of basic cardiac physiology.
May 2, 2023Dr.ASA:DrugsAlteringECG
Conduction Pathways
May 2, 2023Dr.ASA:DrugsAlteringECG
P wave = atrial depolarisation.
PR Interval = impulse from atria to ventricles.
QRS complex = ventricular depolarisation.
ST segment = isoelectric - part
T wave = ventricular repolarisation.
QT Interval = onset of depolarisation to the completion of repolarization of the ventricles.
May 2, 2023Dr.ASA:DrugsAlteringECG
Interpretation
May 2, 2023Dr.ASA:DrugsAlteringECG
FOLLOW THE STEPS
May 2, 2023Dr.ASA:DrugsAlteringECG
1. Rate2. Regularity3. Intervals4. Rhythm5. Axis
Normal RAD LAD No Man’s Land
6. Waveform MorphologyPeaked/biphasic P wavesQRS changes
BBB/conduction delayLow or High VoltagePacer
T-waves Inversions7. ST Segment
ElevationDepression
8. Q-Waves
1. Rate = Number of P’s (atrial) R’s (ventricular) per minute (6 second [30 squares] X 10 = minute rate).
2. Rhythm = Regular or irregular. Map P-P and R-R intervals.
P rate: 8 x 10 = 80 R rate: 8 x 10 = 80
Interpretation
May 2, 2023Dr.ASA:DrugsAlteringECG
3. P wave = present, 1 per QRS, shape, duration, voltage.
4. P-R interval = length (0.12 - 0.2 sec = <1 big square), isoelectric.
Interpretation
May 2, 2023Dr.ASA:DrugsAlteringECG
5. QRS = duration, voltage
6. ST Segment = shape, isoelectric with PR segment
Interpretation
May 2, 2023Dr.ASA:DrugsAlteringECG
7. T wave = shape, direction
8. QT interval = length (R-R/2 or QTc <0.40 sec)
Interpretation
May 2, 2023Dr.ASA:DrugsAlteringECG
Axis determination
NormalRADLAD
May 2, 2023Dr.ASA:DrugsAlteringECG
Abnormalities: Supraventricular
arrhythmias Atrial Fibrillation Atrial Flutter Supraventricular Tachycardia (SVT)
• Premature Ventricular Complexes (PVCs)
Abnormalities: Ventricular arrhythmias
May 2, 2023Dr.ASA:DrugsAlteringECG
Conduction PathwaysSupraventricular Narrow QRS complex
Ventricular Wide QRS complex
May 2, 2023Dr.ASA:DrugsAlteringECG
12 lead EKGBipolar leads : I, II, III
May 2, 2023Dr.ASA:DrugsAlteringECG
12 lead EKGUnipolar Augmented Leads
aVRaVFaVL
May 2, 2023Dr.ASA:DrugsAlteringECG
12 lead EKGPrecordial Leads: V1 V2 V3 V4 V5 V6
May 2, 2023Dr.ASA:DrugsAlteringECG
Leads I, aVL, V5, V6 lateral leads.Leads II, III, aVFinferior leads.Leads V1 to V4anterior chest leads.Leads V1, V2 anterior septal leads
May 2, 2023Dr.ASA:DrugsAlteringECG
Main mechanisms involved
Depressant action(Na+, Ca2+, K+, Na+-K+ ATPase blockers)Action on ANS & its sites of CVS actionOther electrolyte imbalances made by drugs.
May 2, 2023Dr.ASA:DrugsAlteringECG
May 2, 2023Dr.ASA:DrugsAlteringECG
Membrane – depressant drugs and toxinsSodium channel blockers
Slow Calcium Channel Blockers (CCB)Outward potassium channel blockersSodium–potassium ATPase blockers
May 2, 2023Dr.ASA:DrugsAlteringECG
Na+ channel blockers(Inhibitors of fast Na+ channels)
May 2, 2023
CVS drugs Type Ia antiarrhythmicsType Ic antiarrhythmics-Propranolol and other membrane depressant beta-blockersVerapamil, Diltiazem
Psychiatric drugs
CarbamazepineCyclic antidepressantsNeurolepticsAntipsychotics
Other drugs AmantadineDiphenhydramineChloroquine, HydroxychloroquineOrphenadrineNarcotic pain relievers (Propoxyphene)
Illicit drugs CocaineToxins Quinine, Saxitoxin, TetrodotoxinDr.ASA:DrugsAlteringECG
May 2, 2023*Holstege et al., 2005
Dr.ASA:DrugsAlteringECG
ECG changesQRS widening
RBBB pattern
R wave elevation in aVR lead
Rightward deviation of QRS axis
VT & VF
Bradycardia with wide QRS complex
Asystole
ST/T changes consistent with ischemia (cocaine toxicity)
May 2, 2023Dr.ASA:DrugsAlteringECG
May 2, 2023
ACUTE POISONING WITH AMITRIPTYLINE
NORMAL ECG
Sinus tachy 148/min, QRS>/0.12sec, Rwave elev in aVR, QT prol, RAD
Dr.ASA:DrugsAlteringECG
May 2, 2023
SINE WAVE PATTERN
Dr.ASA:DrugsAlteringECG
May 2, 2023
RIGHT BUNDLE BRANCH BLOCKDiagnostic Criteria
•Broad QRS > 120 ms•RSR’ pattern in V1-3 (‘M-shaped’
QRS complex)•Wide, slurred S wave in the lateral
leads (I, aVL, V5-6)QRS >120ms
Slurred SWave
Dr.ASA:DrugsAlteringECG
Slow CCB
May 2, 2023Dr.ASA:DrugsAlteringECG
ECG ChangesSinus bradycardiaReflex tachycardia (ex. Nifedipine)Varying degrees of AV blockSinus arrest with AV junctional rhythmAsystoleWide QRS complexST/T changes
May 2, 2023Dr.ASA:DrugsAlteringECG
ACUTE POISONING WITH VERAPAMIL IN A 61yr OLD FEMALE
May 2, 2023
NORMAL ECG
Sinus brady 41/min, minor RBBB, QTprol
Dr.ASA:DrugsAlteringECG
Outward K+ channel blockers
May 2, 2023Dr.ASA:DrugsAlteringECG
ECG ChangesQT interval prolongationT- or U-wave abnormalitiesPremature ventricular beats (PVP) TdPSinus tachycardia
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May 2, 2023Dr.ASA:DrugsAlteringECG
Na+-K+ ATPase Blockers
May 2, 2023Dr.ASA:DrugsAlteringECG
May 2, 2023Dr.ASA:DrugsAlteringECG
ECG Changes*
May 2, 2023
Excitant activity: AF, Afl, VT VFSuppressant activity: sinus bradycardia, BBB, complete AV block.Combination
*Gordon, 2006; Lapostolle & Borron, 2007Dr.ASA:DrugsAlteringECG
May 2, 2023
The morphology of the QRS complex / ST segment“SLURRED”, “SAGGING” “SCOOPED” ,“REVERSE TICK”, “HOCKEY
STICK” OR“SALVADOR DALI’S MOUSTACHE”!
Dr.ASA:DrugsAlteringECG
May 2, 2023
BIPHASIC T wave with an initial -ve deflection and terminal +ve deflection(v4-6)
First part of the T wave is typically continuous with the depressed ST segment.
Terminal T +ve deflection may be peaked.
Or have a prominent u wave superimposed upon it.
T wave DIGOXIN effect
Dr.ASA:DrugsAlteringECG
May 2, 2023
DIGOXIN EFFECT
NORMAL ECG
Sagging ST segments are most evident in the lateral leads V4-6, I, aVL
Dr.ASA:DrugsAlteringECG
Drugs and toxins acting on ANSBeta-adrenergic blockers
Other sympathetic – inhibitors (other than BB)Sympathomimetic drugs and toxinsAnticholinergic drugs and toxinsCholinomimetic drugs and toxins
May 2, 2023Dr.ASA:DrugsAlteringECG
Beta Blockers
May 2, 2023Dr.ASA:DrugsAlteringECG
ECG changes*
May 2, 2023*Gordon, 2006; Holstege et al., 2006; Brubacher, 2007
Dr.ASA:DrugsAlteringECG
Beta Blockers that Prolong QT intervalSOTALOL
ACEBUTALOL
PROPRANOLOL
May 2, 2023
TdPDr.ASA:DrugsAlteringECG
Other sympathetic – inhibitors (other than
BB)MethyldopaClonidine and other imidazoline derivativesReserpine, GuanethidinePrazosin and other alpha-blockers
May 2, 2023Dr.ASA:DrugsAlteringECG
ECG ChangesSinus, atrial, junctional and ventricular bradyarrhythmiasFirst degree AV block
May 2, 2023Dr.ASA:DrugsAlteringECG
Sympathomimetic toxicity
May 2, 2023Dr.ASA:DrugsAlteringECG
ECG changesSinus tachycardiaAtrial tachycardiaVentricular premature beatsVT, VFMyocardial ischemia or infarction (cocaine, amphetamines, or hydrocarbons ingestion)
May 2, 2023Dr.ASA:DrugsAlteringECG
Anticholinergic toxicity
May 2, 2023Dr.ASA:DrugsAlteringECG
ECG ChangesSinus & atrial tachycardiaPremature ventricular beats
May 2, 2023Dr.ASA:DrugsAlteringECG
Cholinomimetic toxicity
May 2, 2023Dr.ASA:DrugsAlteringECG
ECG ChangesSinus bradycardiaAV blockSinus tachycardia (seen in early stages of cholinesterase inhibition and nicotine poisoning due to ganglionic stimulation)VT associated with QT interval prolongationAsystole
May 2, 2023Dr.ASA:DrugsAlteringECG
May 2, 2023Dr.ASA:DrugsAlteringECG
Drugs of abuse*
May 2, 2023*Albertson, 2004; Albertson et al., 2007, a; Delgado, 2007; Quang, 2007; Traub, 2007; Yip et al.,2007
Dr.ASA:DrugsAlteringECG
Electrolyte Disturbances as AE
HYPERKALEMIA
Peaked T waves
PR prolongation and P wave flattening
QRS widening
HYPOKALEMIA – ST depression, T wave flattening, U waves
HYPOCALCEMIA – Prolonged QT interval
HYPERCALCEMIA – Shortened QT interval
May 2, 2023Dr.ASA:DrugsAlteringECG
May 2, 2023Dr.ASA:DrugsAlteringECG
HYPERKALEMIA
May 2, 2023Dr.ASA:DrugsAlteringECG
LITHIUMCompetes with Na+, K+, Ca2+ & Mg2+ions
QT prolongation, ST segment changes & T wave changes.Sinus bradycardia, AVblocks, cardiovascular compromise.ECG changes chronic overdoses>>acute overdoses*
May 2, 2023Dr.ASA:DrugsAlteringECG
*Linakis J, Woolf A. Clinical features of acute versus chronic lithium overdose. Vet Human Toxicol 1989;31:370.
Combination to be avoided(D/I)ACEI + AMILORIDE/TRIAMTERENE hyperkalemia
LITHIUM + ACEI levels of Li.LITHIUM + LOOP DIURETICS Li.WARFARIN + AMIODARONE risk of bleeding.DIGOXIN + THIAZIDES digitalis toxicity.CCB + BETA BLOCKER bradycardia.SIDENAFIL + NITRATES severe hypotension cardiac death.ACEI + K+SPARING DIURETIC hyperkalemia.
May 2, 2023Dr.ASA:DrugsAlteringECG
DRUGS WITHDRAWN FROM MARKET DUE TO CARDIOTOXICITY
DRUGS
ASTEMIZOLE
CISAPRIDE
PROPOXYPHENE
FEN-PHEN(FENFLURAMINE + PHENTERMINE)
ROSIGLITAZONESIBUTRAMINE
TERFENADINE
ROFECOXIB
YEAR OF WITHDRAWAL
1999
2000
2010
1997
2010
1997
2004
REASON
FATAL ARRYTHMIAS
FATAL ARRYTHMIAS
HEART ATTACKS & STROKE
CARDIOTOXICITY
HEART ATTACK & DEATH
QT PROL & V.TACH
MI & STROKEMay 2, 2023Dr.ASA:DrugsAlteringECG
SummaryECG is a valuable source of information in poisoned patients and has the potential to enhance and direct their care.
Many drugs with no overt cardiovascular effects from therapeutic dosing become cardiotoxic in overdose.
Knowledge of drug PK PD & ADR profile is a mandatory thing before prescription.
Main blocker drugs that affect heart--Na+, K+ Ca++, Na-K ATPase.
Others being the one acting on ANS, drugs of abuse etc
Irrational use of drugs may create much financial burden to a country.
ECG should be examined extremely early in initial evaluation of most poisoned cases. May 2, 2023Dr.ASA:DrugsAlteringECG
REFERENCESAlbertson, T.E. (2004). Amphetamines, In: Poisoning & Drug Overdose, 4th Ed., Olson, K.R. et al. (Eds.), pp. 72-74, Lange Medical Books/McGraw-Hill, ISBN 0-8385-8172-2, NewYork, USA.
Anderson, A.C. (2008). Management of Beta-Adrenergic Blocker Poisoning. Clinical Pediatric Emergency Medicine, Vol. 9, No. 1, (March, 2008), pp.4-16, ISSN 1522-8401.
Holstege, C.; Baer, A. & Brady, W.J. (2005). The ECG toxidrome: the ECG presentation of hydrofluoric acid ingestion. American Journal of Emergency Medicine,Vol. 23, No.2, (March 2005), pp.171-176. ISSN 0735-6757.
Lionte C et al: Toxic and Drug-Induced Changes of the ECG, ”Gr.T.Popa” University of Medicine and Pharmacy, Iasi, Romania
Puhr J et al: Lithium overdose with ECG changes suggesting ischemia, Toxicology observation North Carolina.
May 2, 2023Dr.ASA:DrugsAlteringECG