ECG cases, Education

Dr. Hana Hybasek Dzurikova, MRCVS, PGCert MEd

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29. January 2025

Unmasking Hyperkalemia: Highlighting Critical ECG Changes

ECG cases, Education

Hyperkalemia, defined as serum potassium levels exceeding 5.0 mEq/L, is a silent but deadly threat. Its potential to cause life-threatening arrhythmias¹ makes early recognition crucial in emergency medicine. If left undiagnosed, it can rapidly disrupt cardiac electrical activity, progressing to cardiac arrest. Early detection and prompt management are crucial to prevent adverse outcomes, especially as hyperkalemia is one of the most common reversible causes of cardiac arrest.²

ECG is a widely accessible and non-invasive diagnostic tool, invaluable in detecting hyperkalemia by revealing characteristic ECG changes.³,⁴ This article explores the key ECG characteristics of hyperkalemia, highlighting how it can mimic hyperacute T waves, a common STEMI equivalent pattern, and its clinical significance. Furthermore, it examines the capability of advanced AI-based platforms like PMcardio to enhance diagnostic precision by differentiating between hyperkalemia-induced ECG abnormalities and true myocardial infarction (MI) patterns.

First Signs of Hyperkalemia on the ECG

Elevated extracellular potassium disrupts sodium influx into cardiac cells, decreases myocardial conduction velocity while accelerating the heart’s repolarization phase, resulting in a distinct sequence of changes on the surface ECG.⁵One of the earliest and most characteristic ECG patterns is the appearance of peaked T waves. However, it is not simply the height of these T waves that is crucial, but rather the narrowing of their base^6,7. As potassium levels increase, conduction through the atrioventricular (AV) node slows down, causing the PR interval to extend beyond the normal range of greater than 200 milliseconds.

Hyperkalemia - ECG changes — Figure 1: This ECG likely shows sinus bradycardia with small or depressed P-waves and a prolonged PR interval. The QRS complex measures approximately 150 ms and exhibits morphology consistent with left anterior fascicular block (LAFB). The T-waves are notably peaked, all of which are findings indicative of hyperkalemia. (Dr. Smith’s ECG Blog, digitized by PMcardio)

Figure 2: ECG diagnostic of hyperkalemia, which can produce a variety of pseudo-STEMI or pseudo-OMI patterns, including ST elevation, ST depression, and prominent T-waves. The T-waves here are tall with a narrow base and are accompanied by a flattened ST segment, as seen in lead V4. Additionally, there are no definite P-waves, another hallmark of hyperkalemia. Interestingly, in some cases, the sinus node remains active as the pacemaker, but P-waves are not visible. This phenomenon is known as sino-ventricular rhythm. (Dr. Smith’s ECG Blog, digitized by PMcardio)

The Severe Manifestation: Sine-Wave Patterns

In the most severe stages of hyperkalemia, the QRS complex progressively widens, the T waves broaden and may eventually merge with the widened QRS complexes with the equally wide and broad-based ST-T segments, producing the classic “sine-wave” pattern. In the absence of visible P waves, this can easily be mistaken for an idioventricular rhythm or ventricular tachycardia, further complicating diagnosis and management.⁵

ECG diagnostic of hyperkalemia - severe stages of hyperkalemia — *Figure 3: The ECG demonstrates a sine wave pattern, a characteristic finding in severe hyperkalemia. (Dr. Smith’s ECG Blog, digitized by PMcardio)*

A Closer Look at Clinical Significance

Early and accurate identification of ECG changes has critical implications for patient outcomes, particularly in emergency settings. Notably, attempting defibrillation in ventricular rhythm, when severe hyperkalemia remains untreated, often precipitates asystole due to atrial arrest, emphasizing the critical importance of accurate diagnosis before initiating potentially harmful interventions.⁸

In terms of clinical importance, the nature of the ECG changes serves as a more reliable predictor of outcomes than the serum potassium level itself.⁹ Remarkably, there are reports of patients with severely elevated potassium levels, reaching as high as 8.3 mEq/L, who display minimal or no significant ECG changes.¹⁰

Brugada Phenocopies in Hyperkalemia: ECG Features Mimicking STEMI

In severe cases of hyperkalemia, the ECG can mimic the ST-elevation pattern seen in myocardial infarction (STEMI). These changes result from alterations in cardiac membrane potential due to elevated potassium levels and often manifest prominently in anterior or precordial leads.¹¹ Such patterns may resemble Brugada syndrome^12,13, particularly in the right precordial leads (V1-V3). However, Brugada phenocopies differ from true Brugada syndrome as they are transient and arise from reversible causes such as metabolic disturbances, including hyperkalemia. These changes typically resolve with the correction of the underlying metabolic abnormality.

case of hyperkalemia, the ECG can mimic the ST-elevation pattern seen in myocardial infarction (STEMI) — *Figure 4: The QRS duration is 153 ms. Note the ST elevation in V1 and V2, exhibiting a Brugada-like pattern with definite P-waves absent. (Dr. Smith’s ECG Blog, digitized by PMcardio)*

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Distinguishing Hyperacute T Waves: Hyperkalemia vs. Hyperacute T-waves (HATW)

Despite advancements in detecting and treating acute coronary syndromes (ACS), MI remains a leading cause of mortality globally.¹⁴Early identification of acute coronary occlusion and prompt initiation of reperfusion therapies are crucial to improving survival in patients with ST-segment elevation myocardial infarction (STEMI).¹⁵ However, the spectrum of ECG changes indicating acute coronary ischemia extends beyond the classic ST-segment elevation, encompassing less-recognized STEMI equivalents. Patients presenting with these atypical patterns, despite having acute coronary occlusion, are at risk of delayed revascularization, often leading to poorer outcomes and a worse prognosis.^16,17 Alarmingly, only about 43% of acute myocardial occlusions meet the conventional STEMI millimeter criteria, highlighting a critical need for enhanced diagnostic vigilance.¹⁸

Hyperacute T-waves (HATW) are characterized by their increased height and width, along with a notably symmetric shape compared to normal T waves. This symmetry, combined with a broader base, leads to QT interval prolongation, recognized as one of the earliest detectable changes in acute coronary occlusion.¹⁹ Notably, a distinguishing attribute of these hyperacute T waves is their restriction to the myocardial region supplied by the occluded coronary artery.²⁰This localized presentation, together with the changes in height, width, and QT interval, makes hyperacute T waves a critical marker for identifying acute coronary events on an ECG. In a small percentage of cases, tall, symmetrical, and upright T waves may remain for several hours without the emergence of ST-segment elevation, despite the presence of a fully occluded epicardial coronary artery.²¹

Unmasking Hyperkalemia: Highlighting Critical ECG Changes — Figure 5: The ECG shows large, symmetric T-waves in leads I, aVL, and V2–V5, which are diagnostic of a proximal LAD occlusion. Down-up T-waves are observed in leads III and aVF. (Dr. Smith’s ECG Blog, digitized by PMcardio)

Empowering Acute Care: AI-Driven Detection of Hyperkalemia

Although emergency physicians demonstrate high specificity in ECG interpretation, their sensitivity for diagnosing hyperkalemia remains limited.²² Leveraging AI-powered tools like PMcardio provides a critical advantage by enabling clinicians to make timely, informed decisions. Most importantly, PMcardio excels in distinguishing hyperacute T waves caused by acute occlusive myocardial infarctions from those associated with hyperkalemia. This capability is vital to prevent missed diagnoses of acute MI, ensuring patients receive rapid and appropriate treatment.

Conclusion

Hyperkalemia presents a unique diagnostic challenge due to its ECG changes, particularly peaked T waves, which can closely mimic hyperacute T waves – a critical STEMI equivalent pattern indicative of acute coronary occlusion. Misinterpreting these patterns can lead to delays in life-saving interventions. PMcardio leads the way in identifying hyperacute T-waves, ensuring the rapid detection of STEMI equivalents and facilitating prompt decision-making for STEMI management.²³ While the definitive diagnosis of hyperkalemia requires blood tests, PMcardio’s ability to discern key ECG patterns supports clinicians in distinguishing between acute coronary events and other conditions, ultimately enhancing care in time-sensitive scenarios.

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References

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Dr. Hana Hybasek Dzurikova, MRCVS, PGCert MEd

Dr. Hana Hybasek Dzurikova, MRCVS, PGCert MEd is a medical educator driving innovation and change in health professions education through technology-enhanced learning.

About PMcardio:

PMcardio is the market leader in AI-powered diagnostics, addressing the world’s leading cause of death – cardiovascular diseases. The innovative clinical assistant empowers healthcare professionals to detect up to 40 cardiovascular diseases. In the form of a smartphone application, the certified Class IIb medical device interprets any 12-lead ECG image in under 5 seconds to provide accurate diagnoses and individualized treatment recommendations tailored to each patient.

About Powerful Medical:

Established in 2017, Powerful Medical has embarked on a mission to revolutionize the diagnosis and treatment of cardiovascular diseases. We are a medical company backed by 28 world-class cardiologists and led by our expert Scientific Board with decades of experience in daily patient care, clinical research, and medical devices. The results of our research are implemented, developed, certified, and brought to market by our 50+ strong interdisciplinary team of physicians, data scientists, AI experts, software engineers, regulatory specialists, and commercial teams.