ISSUE 1

• HEART LINKS SPRING 2005

The Cardiac Newsletter for Lincolnshire

EDITORIAL BOSTON CARDIAC CARE
TEAM WIN BPICC AWARD
Welcome to the first issue of Heart Links, a
quarterly newsletter written for anyone with an Pilgrim Cardiology Nurses and the Lincolnshire
interest in cardiology and the management of Ambulance Service have recently been awarded the
“Best Practice in Integrated Cardiac Care Award
patients with acute coronary syndromes. This 2004”.
newsletter is produced within Lincolnshire and
will contain updates and information about the In the UK, more than 270,000 people each year have
activities of teams working in the community heart attacks and the BPICC Award recognises that
and in secondary care across the county. You cardiac care services all over the country are
will also find regular teaching articles, case continually being put to the test to ensure quick and
studies and competitions (with prizes!). If you safe responses to meet the tough government
targets set by the NSF for CHD for Acute Myocardial
would like to contribute material for future Infarction patients. Targets include the delivery of
issues please contact Jacqui Larder at: thrombolysis within 60 minutes of calling for
professional help (call-to-needle time) or within 30
Jacqui.Larder@EastLincs-PCT.nhs.uk. minutes of arrival at hospital (door-to-needle time,
I hope you find this and future issues both DTNT).
interesting and informative and we would The combined nursing, paramedic and cardiology
welcome your suggestions as to how we can team have dramatically improved their DTNT with a
improve the content. number of initiatives including a “staff swap” pilot
scheme allowing nurses to spend time with
Dr Andrew R. Houghton (Editor) paramedic teams and vice versa. In addition, PGDs
Consultant Cardiologist have been introduced for the administration of pre-
Grantham & District Hospital hospital thrombolysis by paramedics before the
patient reaches the hospital.

Maria Willoughby, Cardiac Assessment Nurse from

ARTICLES OF INTEREST IN THIS ISSUE
MAKING SENSE OF THE ECG
By Dr Andrew Houghton
Part 1: PUTTING THE ECG IN CONTEXT
CASE HISTORIES
MINAP INFORMATION
WEB LINK OF THE MONTH
LETTER PAGE
COMPETITION
Pilgrim Hospital, commented: “We are delighted to
have won the BPICC Award as it is recognition for
the hard work that ambulance, emergency and
cardiac care teams have put into improving cardiac
care in the Boston region”.
The Lincolnshire team were awarded the first prize of
£2,500, which will go towards team training or
equipment.
Maria.Willoughby@ulh.nhs.uk

Editorial Team: Dr Andrew R. Houghton (Editor), ULHT

Jacqui Larder, Trent Cardiac Network
Nick Sentence, Lincolnshire Ambulance Service
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 Making Sense of the ECG
Dr Andrew R. Houghton, Consultant Cardiologist (Grantham & District Hospital)

Part 1: Putting the ECG in context

The 12-lead ECG is a remarkably useful and
versatile investigation. It can help us to diagnose
and assess arrhythmias, myocardial ischaemia or
infarction, cardiomyopathies, electrolyte disorders
and a host of other conditions.
So what can be done to avoid these pitfalls?
If you’re interpreting an ECG, always ask for the
clinical context of the recording before making your
assessment - be sure to check:

However, the ECG can also be misleading,
particularly when interpreted out of context. Clinical
context is all-important - never be tempted to
interpret an ECG without knowing the
circumstances in which it was recorded.
For instance, what does the following ECG show?
The knee-jerk response is to say “ventricular
fibrillation” and to reach for a defibrillator. If the
ECG had been recorded in the context of a patient
who was unresponsive and pulseless that would
certainly seem appropriate.
One final example…what does this complex (taken
But what if the patient is alert and well? This could from lead V5) show?
simply be muscle artefact - perhaps the patient
has a tremor, or is brushing his teeth. The clinical
context makes a huge difference to the
interpretation.
1. Whether there is any relevant past medical
history (is the patient hypertensive or taking any
relevant medication?).
2. Whether the patient had any symptoms during
the ECG recording - always ask: “How was the
patient feeling?”
If you’re recording an ECG, always be sure to
make a note of any relevant history or symptoms at
the top of the recording, along with patient’s ID
details and the date/time of the recording. A
frequent example in a CCU setting is “Chest pain,
severity 6/10”. If the patient is asymptomatic, say
so. When someone else comes to review the ECG
later, he or she will then be able to make an
appropriate interpretation in the light of the clinical
context.

Take another example - what does the following

ECG show? There is clearly downsloping ST segment
depression, but what is the cause?

One possibility is left ventricular hypertrophy with

“strain” - so it would help to know if the patient has
a history of hypertension. Another possibility is
Again, the immediate response is to say “normal myocardial ischaemia - so we need to know if the
sinus rhythm”, and in the context of a patient who patient was experiencing chest pain at the time of
is alert and well that would seem reasonable. the recording.

But what if the patient is unconscious and
pulseless? The diagnosis then would be pulseless
electrical activity (PEA). Once again, the clinical
context is all-important.
In fact it’s a patient taking digoxin, with the
classical “reverse tick” ST segment depression - an
easy diagnosis, but only if the person who
recorded the ECG has written “Taking digoxin
250mcg daily” at the top.

Next issue - Part 2: Assessing heart rate

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 CASE HISTORIES
CASE 1: A 60 YEAR OLD FEMALE WITH CHEST PAIN
A 60 year old lady presented via the ambulance service to A&E after 1 hour of chest pain. She had had a
sharp, central chest pain with no radiation; it had been worse during exercise and was relieved by rest.
She had no SOB but was warm and sweaty on examination. She has no previous cardiac history,
although she had experienced a similar episode 5 weeks earlier which lasted 20 minutes while walking
uphill.

What are your observations of this ECG?

After two days in hospital her ECG now looked like this.
What is your diagnosis and recommended treatment, considering that she had remained pain free
since admission?

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On day four she was discharged home. The following morning she represented after further chest
pain. Her ECG now looked like this. What is your treatment plan?

On contacting CCU, they were happy to review this patient, her discharge ECG was almost
identical to the ECG above. Does this change your plan?

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 CASE HISTORIES
CASE 2: A 54 YEAR OLD MALE WITH CHEST PAIN
A 54 year old gentleman called for an ambulance after 1 hour of severe central chest pain,
associated with SOB, sweating, nausea, with no radiation.

The crew, fearing the worst, appropriately red called the patient in.

He smoked 20 cigarettes a day despite having an MI 5 years previously.

Normally hypertensive. He was also a heavy drinker of 40+ units a week.
Pain felt like similar pain to MI.

Family history – mother and father had IHD

He was pale, sweating and was restless and feeling very unwell.
Blood pressure 149/93.

What is your diagnosis and treatment?

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 CASE HISTORIES
CASE 3: A 63 YEAR OLD MALE WITH CHEST PAIN
A 63 year old male arrived at A&E with a 5 day history of chest pain radiating down left arm.
No other associated symptoms.
Smoker of 20 a day.
Drinks 10 units 3 –4 times a week.

What are your ECG findings?

What is your treatment?

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 CASE HISTORIES
CASE 4: A 50 YEAR OLD MALE WITH CHEST PAIN
A 50 year old male presented at 17.36 on 10.9.04.
Red Call to resus with 30 minutes of central chest pain.

This gentleman almost had pre-hospital thrombolysis; unfortunately he had had surgery 4 weeks
prior for a detached retina. This left the paramedic unable to deliver the Reteplase. On arrival
in the ER and during questioning he promptly went in to VF. Following an unsuccessful
pre-cordial thump, a 200J shock was administered with the desired effect.
He had severe pain radiating to left and right arms. Pain was burning in nature.
He was vomiting and sweaty.
Life long smoker, smoking 20 a day.
Positive family history. Father had an MI at 45.
Drinks 40+ units a week.

What is your diagnosis and treatment?

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 CASE HISTORIES
CASE 5: AN 86 YEAR OLD MALE WITH CHEST PAIN
An 86 year old male. Complaining of chest pain since 00:00 hrs.
Presented at A&E at 16:23 hrs.

He was experiencing central chest pain radiating to his arm, shoulder, neck and jaw.
The pain had come on at rest. The pain felt like his previous MI.
He was also SOB and sweating.

PMH: CCF
MI
?Hypertension

What are your ECG findings?

Would you thrombolyse this patient?

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 CASE HISTORIES
CASE 6: AN 81 YEAR OLD FEMALE WITH DIZZINESS
An 81 year old lady presented with a sudden onset of dizziness but no LOC.
No chest pain.

What rhythm is this lady in?

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 CASE HISTORIES
CASE 7: AN 80 YEAR OLD MALE WITH CHEST PAIN
An 80 year old gentleman arrived via ambulance service at 07:50 hrs.
He had central chest pain since 5 a.m., radiating through to his back.
He was complaining of SOB, sweating and felt dizzy.
He had pins and needles down both arms and into his hands.
The pain was getting worse. He had taken GTN without effect.
He had had a similar episode 1 week ago.

PMH Right ventricular and posterior

Hypertension leads were completed.
Diverticulitis Nothing abnormal found.

What are your ECG findings, how would you treat and would you thrombolyse?

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 CASE HISTORIES
CASE 8: A 57 YEAR OLD MALE WITH CHEST PAIN
A 57 year old gentleman arrived in A&E at 00:52 hrs.
He had had pain since 22:50 hrs. He had no radiation of pain.
He did however feel dizzy, had difficulty in breathing and was nauseated and vomiting.
His pain score was 7/10.

PMH MEDICATION
CABG Atenolol
Stent Tildiem
MI x 3 Aspirin
ISMN

The ECG changes are…?

The patient was actually seen by a Paramedic who decided that the patient was having an MI.
Following his criteria, he continued to give 5000 units of Heparin and 10 units of Reteplase.

Was this the right decision?

ACKNOWLEDGEMENT:
Our thanks to Glen Sibbick from the Leicestershire,
Northamptonshire and Rutland Cardiac Network whose original idea
it was to produce a cardiac newsletter and in “the spirit of noble
plagiarism” (see Dr Richard Andrew’s letter) generously allowed us to copy
his idea and case histories. Can we start collecting some of our own
please?

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 CASE HISTORIES
CASE 9: A 90 YEAR OLD FEMALE WITH CHEST PAIN
A 90 year old lady was red called to the emergency room from ambulance control.
She described a heavy pressure type pain in the centre of her chest.
She had been resting when the pain had come on, rated 9/10.
She was sweating, SOB and felt nauseous. The pain had started some 11/2 hours ago.

PMH MEDICATION
Hypertension Bendroflumethiazide
Ramipril

She lived in residential/sheltered accommodation and was normally fit and well.
Completely self caring and independently mobile.
She looked young for her age, and could have been mistaken for being less than
70 years of age.

What would you do now?

What can you see on the ECG?

Should you thrombolyse?

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 CASE HISTORIES - ANSWERS 1-5
Case 1
Initial ECG looks unremarkable. It highlights any complacency you may have for a “normal ECG”.
The second ECG, 24 hrs later, shows deep arrowhead “T” wave inversion in V2 – V5; this is of concern.
Not all ECGs will show up problems, the second ECG suggests a lesion on her LAD.
So from this we need to be aware that although the 1st ECG does not pick up problems immediately, it does
reinforce the need for an overnight stay with a Troponin at 12 hours including serial ECGs.
CK = 82, Trop I = 0.98. These levels are consistent with the evolving damage that has occurred. As the third ECG
was very similar to her discharge ECG, no further action was taken, however she did stay in hospital for an
angiogram at Glenfield Hospital. Angiogram found a critical lesion on her distal LAD. However, as it was a tortuous
vessel, and small, medical treatment was chosen.

Case 2
ECG findings: ST elevation in I, AVL with reciprocal changes in II, III, and AVF.
He also has hyperacute T’s in V2 – V6.
Diagnosis: Anterolateral MI. Interestingly his CK rise was only 146.
With his history, presentation and ECG findings we went on to thrombolyse. He was also given IV Atenolol 3mg.
His call to needle time just missed the 60 minute target by 3 minutes.

Case 3
ECG shows deep arrow head T wave inversion in leads V2 – V5 and T wave inversion in I, AVL, V6.
As you will have read from Case 1, this is either a NSTEMI (non ST elevation MI) or unstable angina, in either case
consistent with a lesion in his LAD (Left Anterior Descending) coronary artery.
CK= 369, Troponin I = 1.74. He was started on Tirofiban and heparin, and referred for an angiogram at Glenfield
Hospital.

Case 4
ECG shows ST elevation II, III, AVF. ST Depression, I, AVL, V2 – V6. Changes in V1 – V4.
Consider posterior involvement (nil found in V7 – V9) but ST elevation was found in right sided chest leads.

Diagnosis: Acute inferior infarct (STEMI).

Despite the issues around his eye surgery, he was subsequently given Reteplase 10 units.
2nd CK 2770.
Eyesight has not deteriorated.
Despite slight delay with the VF he was successfully thrombolysed within the 60-minute target.

Case 5
ECG shows LBBB (and AF as no obvious P waves and irregular rhythm).
Normally with LBBB it is not possible to comment on ST segment (you can with RBBB). But the ST segment on the
inferior leads II, III, AVF do look suspicious and combined with his previous MI and presenting complaint he was
thrombolysed, with Reteplase.

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 CASE HISTORIES - ANSWERS 6-9
Case 6
This very similar ECG to the previous case. However this lady has a pacemaker in situ.
The widening of the QRS you are seeing is normal and consistent with someone who has a
pacemaker. It is a dual chamber pacemaker (DDD), as it appears to be tracking her own sinus rate.
Sometimes the pacing spike can be lost if the ECG machine has the filter on. Repeat with the filter off if you are
unsure.

Case 7
ECG suggests ST elevation in leads II, III, AVF. ST depression in I, AVL, V1-V6.
ST segment depression seen here in V2 and V3 could be consistent with a posterior MI.
Posterior leads should be completed as soon as practical.
ST depression of greater than 3mm is found to be 90% specific for MI.
After excluding any contra-indications to thrombolysis, Reteplase 10 units was given. Also Diamorphine and
Metoclopramide.
The patient made a full recovery and went home 4 days later
CK rise >262, Troponin 28.56

Case 8
ST elevation in II, III, AVF, V6. Good reciprocal changes in I, AVL.
The ECG is consistent with a inferior MI, but with elevation in V6, there is also lateral wall involvement.
Subsequent ECGs show ST elevation in V5 as well.
The decision to thrombolyse was a good one. CK rise 2485

Case 9
ECG shows LBBB.
Normally you are unable to comment on the ST segment with LBBB, so we just have to decide whether it is new or
old. No old ECGs to go on.
The other observation is that there does appear to be ST elevation in V1-V6 , probably most noticeable in
V4 and V5. She looked good for her age and the fact she was normally independent, with no contra-indication to
thrombolysis, she was treated with Reteplase.
CK rose to 3054.

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 NEWS
Working together for the patient
We all have a 60 minute target to meet……….together. The new target encourages a
seamless service between the ambulance service and the receiving hospital. From the
time the patient calls for help (call time) to the time thrombolysis is given (if appropriate),
should be no more than 60 minutes.

This target is a tough target to achieve in rural Lincolnshire, but both ambulance and
hospitals may be assessed on star ratings for this target. So it is in our interest to see
this being met. Using blue lights with sirens, combined with a courtesy call can save
valuable minutes. If we know that a patient is coming we can often halve the door to
needle time.

Can you help us with complete data? Yes you can!!

The recording (or non-recording) of times on the Patient Report Forms creates an awful
lot of work for Audit staff , both in the Ambulance Trust and in ULHT as well as staff in
Clinical Effectiveness who gather data for MINAP.

The main area of concern for the hospitals is the “Time of Call”. The current PRF in use
with the Ambulance Service does not record the time of call but does record the time that
the incident was passed to the crew. Unfortunately these times may not be the same.

Ambulance Crews are now being advised that ALL timings should be taken from their
Mobile Data Terminals and recorded on their PRF.

The Hospitals use the Atomic Clock to record their timings for CHD events and the use of
the MDT for recording of Ambulance times will ensure that all timings are as accurate as
possible.

PRIMARY ANGIOPLASTY
In the future primary angioplasty may well become the treatment for MI’s.
In some parts of England this is already a routine treatment, but it does require cath lab
support, 24 hours a day, seven days a week. Current research suggests that small
delays in conventional treatment appear not to be detrimental.

Web link of the Month - http://www.heartcenteronline.com

This is a great web site for staff, students and patients. It has some great animated video clips of plaque
rupture and angioplasty and stents, well worth a look. If you link in to the “All animations” you will find
clips on bradycardia, regurgitation, diabetes, plaque rupture, PTCA and stenting etc. It has around 25
animations of about 1-3 minutes each, which take a while to down load if you do not have broadband.
If you know of a worthy web site let me know and I will publish it in subsequent issues.

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 LETTERS
Dear Dr Protheroe,

I should like to express my appreciation and gratitude to the Lincolnshire Ambulance Service for
the prompt response and first class treatment I received when I had my heart attack on 5
September.

The ambulance arrived within minutes of the 999 call and the paramedics were absolutely
marvellous, losing no time in either diagnosis or treatment with the new clot busting drug. They
even came to see me in the afternoon in CCU to see how I was progressing. I am pleased to
say that I am now recovering very well and very quickly.

Once again I would like to thank the Ambulance Service and the paramedics concerned for their
excellent treatment.

Yours sincerely,

Letter received from Patient.

Dear Reader,

Welcome to the first edition of the Heart Links newsletter. We know that throughout
Lincolnshire you are all achieving high quality patient care and often with limited resources.
What we are bad at is telling other people about it! We work within a big county and links and
communications between our workplaces are often patchy.

The aim of this newsletter is to try and share examples of good practice and of innovation in
service delivery. The ethos of the Trent Cardiac Network could be summed up as the ‘spirit of
noble plagiarism’. So if you have improved your service then tell us about it! Most of us will
gladly copy than reinvent the wheel for ourselves, so please forget your natural reticence (some
of my colleagues have no such problem!) and tell us about it. There will also be a modest
attempt to educate and entertain and if you have an interesting case or ECG then please pass it
on so others can also learn from your experience.

We hope that this newsletter will thrive but to do so it really does need to have your
contributions and enthusiasm so please be forthcoming. As a county we have moved a long
way in the last few years in the service we give to cardiac patients and we hope that with your
help this newsletter will be another contribution.

Dr Richard Andrews,
Consultant Cardiologist, Lincoln County Hospital
Clinical Lead, Trent Cardiac Network

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 COMPETITION!
WIN! WIN! WIN!

A copy of “Making Sense of the ECG – A Hands-On Guide”

by Andrew R. Houghton and David Gray

To enter this competition, simply name the coronary arteries labelled 1” and “7” “
on the diagram below and send your answers via e-mail to:

jacquilarder@EastLincs-PCT.nhs.uk

no later than 20th April 2005.

First correct answer drawn out wins!

SUMMER 2005 ISSUE will be published in June

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