From the Guidelines
The management plan for a patient with an abnormal EKG finding should prioritize immediate intervention for life-threatening conditions, such as ST-elevation myocardial infarction, complete heart block, or ventricular tachycardia, with cardiac monitoring, IV access, and emergency services activation. For less urgent findings, management may include rate control medications, anticoagulation, and referral to cardiology. The approach should balance treating the underlying cause while addressing symptoms and preventing complications, aiming to restore normal cardiac function and electrical activity.
Key Considerations
- Compare the abnormal EKG with previous tracings to determine if the finding is new or chronic.
- For potentially life-threatening abnormalities, immediate intervention is necessary, including cardiac monitoring, establishing IV access, and activating emergency services.
- For less urgent findings, management may include:
- Rate control medications (e.g., metoprolol 25-100mg twice daily or diltiazem 30-120mg three times daily) 1.
- Anticoagulation with apixaban 5mg twice daily or warfarin titrated to INR 2-3 if indicated.
- Referral to cardiology.
- Asymptomatic patients with minor abnormalities may simply need follow-up monitoring.
- Additional diagnostic testing often includes cardiac biomarkers (troponin), electrolyte panels, and echocardiography to assess structural heart disease.
Recent Guidelines
The 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay emphasizes the importance of a 12-lead ECG in the initial evaluation of suspected bradycardia or conduction disorder 1. The guideline also highlights the prognostic value of an abnormal initial ECG in patients presenting with syncope and near syncope.
Clinical Decision-Making
The management approach should be individualized based on the patient's specific abnormality, clinical presentation, and underlying medical conditions. For example, patients with cocaine-associated chest pain may require a different management approach, with a focus on addressing potential myocardial infarction and cardiac conduction abnormalities 1. In contrast, patients with atrial fibrillation may require rate control and anticoagulation to prevent stroke and other complications.
From the Research
Management Plan for Abnormal EKG Finding
The management plan for a patient with an abnormal electrocardiogram (EKG) finding depends on the type and severity of the abnormality.
- Patients with abnormal EKGs but no clear evidence of ischemia, such as left bundle branch block (LBBB), right bundle branch block (RBBB), or left anterior hemiblock (LAH), have a relatively low incidence of myocardial infarction (MI) 2.
- Patients with abnormal EKGs questionable for ischemia, such as nonspecific ST and T wave changes, have an intermediate risk of acute myocardial infarction 2.
- Patients with abnormal EKGs demonstrating ischemia, such as acute ST segment elevation and/or depression, are at high risk for acute myocardial infarction and should be admitted to the hospital for further evaluation and management 2.
Diagnostic Tools
In addition to EKG, other diagnostic tools such as echocardiography can be used to evaluate patients with suspected myocardial ischemia.
- Echocardiography has a high sensitivity for identifying patients with myocardial infarction and can predict cardiac events in emergency department patients with possible myocardial ischemia 3.
- However, echocardiography may not be helpful in establishing a diagnosis of syncope in patients with normal EKG and normal physical examination 4.
Risk Stratification
Patients with abnormal EKG findings should be risk-stratified based on their cardiac risk profile, including factors such as age, gender, hypertension, diabetes, smoking, and known coronary artery disease 2.
- Patients with high-risk profiles may require more aggressive management, including hospital admission and further diagnostic testing.
- Patients with low-risk profiles may be eligible for outpatient evaluation and management.
Signal-Averaged ECG
Signal-averaged ECG (SAECG) can be used to detect abnormal heart rhythms and predict arrhythmic events in patients with nonischemic dilated cardiomyopathy 5.
- An abnormal SAECG is a marker of past and future arrhythmic events in patients with nonischemic dilated cardiomyopathy.
- Patients with an abnormal SAECG have a statistically significant increase in sustained ventricular arrhythmias and/or death compared to patients with a normal SAECG.