Wavy Triple An ECG Sign (Yasser’s Sign) in Hypocalcaemia.pptx

Aim of the study: Aim of the study is a clearing of the presence of Wavy triple an electrocardiographic sign (Yasser sign) in hypocalcemia and its diagnostic and therapeutic value. Background: Hypocalcemia is a well-known serious electrolyte disturbance characterized by calcium deficiency. It is associated with non-specific electrocardiographic changes. Method of study and patients: My case study was an observational retrospective 37-case report series. The study was conducted in both Fraskour Central Hospital and (in both the Emergency Department, Internal Ward, and Intensive Care Unit) and Physician Outpatient Clinic. The author reported the 37-cases through nearly 15-months, started from March 12, 2018, and, ended on Jun 8, 2019. Tetany or latent hypocalcemia are included. Parenteral or oral calcium preparation was supplied. Results: The Mean age was: 38.4 years, with female sex predominance (72.97%). Hyperventilation syndrome (45.95%) and malnutrition (24.32%) are the most common risk factors. Carpopedal spasm was the main complaint (89.19 %). Manifested tetany was the commonest final diagnosis (89.19 %). The Wavy triple sign is a positive and triple sign in 97.3% (36 cases) but it is only double in 2.7% (1 case). The Mean number of affected electrocardiographic leads: 4.13, Max.:10, and Min.:1). The number of affected ECG leads correlate with the level of ionized calcium in the investigated group. Electrocardiographic recovery after calcium administration in the first group was completed in 97.3% vs. partial in 2.7%. Conclusions: The Wavy triple an electrocardiographic sign (Yasser sign) is a new diagnostic sign seen in 97.3% (36 cases) of hypocalcemia. Dramatic improvement of both clinical manifestation and the new electrocardiographic sign simultaneously after calcium replacement had happened.

1. Wavy Triple Electrocardiographic Sign (Yasser’s Sign) in Hypocalcaemia -A Novel Diagnostic Sign; Retrospective Observational Study Dr. Yasser Mohammed H assanain Elsayed Scientist and Independent researcher Critical care physician and cardiologist Egyptian Ministry of Health

2. Wavy Triple Electrocardiographic Sign (Yasser’s Sign) in Hypocalcaemia-A Novel Diagnostic Sign; Retrospective Observational Study

3. Figure 1 ; Graphical presentation for Wavy Triple sign of hypocalcemia (Yasser’s sign)

4. Learning objectives   •  The study method and data •   Discovery •  Principles and understanding of the Wavy triple electrocardiographic sign •   Introducing examples for understanding •  The study data and statistics • Mechanisms of Wavy triple sign • Differential Diagnosis •  How to deal with it? (Management) •  Summary •  Conclusion and Recommendations

5. Table 1- showing remarks of the study method and data. Issue Definition Title   Wavy Triple An Electrocardiographic Sign (Yasser’s Sign) in Hypocalcaemia-A Novel Diagnostic Sign Estimated Enrollment 37 participants Study Type Observational Observational Model Case-only Time Retrospective Study Start Date March 12, 2018 Estimated Study Completion Date Jun 8, 2019 Analytic method Comparative using percentage %

6. Discovery   •   Discovery was an accidental •  Precise clinical and electrocardiographic observation. . The researcher will be lucky if the case report will be including deviation from the straight line. . Sometimes, the case report takes multiple ways in understanding. . The physician should be a strong observer of the new clinical findings.

7. Principles of the Wavy triple electrocardiographic sign (Yasser’s sign)   •   The analysis for this sign in the author interpretations are based on the following; 1. Different successive three beats in the same lead are affected. 2. All ECG leads can be implicated. 3. An associated elevated beat is seen with one of the successive three beats, a depressing beat with the second beat, and an isoelectric ST-segment in the third one.

8. 4. The elevated beat is either accompanied by ST-segment elevation or just an elevated beat above the isoelectric line. 5. Also, the depressed beat is either associated with ST-segment depression or just a depressing beat below the isoelectric line. 6. The configuration for depressions, elevations, and isoelectricities of ST-segment for the subsequent three beats are variable from case to case. So, this arrangement is non-conditional. 7. Mostly, there is no participation among the involved leads. The author intended that is not conditionally included in an especial coronary artery for the affected leads.

9. Let me to introducing examples for understanding   Case No. 1 A 28-year-old married Egyptian housewife female patient presented to ED with carpopedal spasm. The patient gave a recent history of poor nutritional status due to psycho-social troubles . Two-calcium gluconate ampoules 10 ml 10% over IV over 20-minutes were taken. Complete clinical and ECG recovery ( Figure 2 ).

10. Figure 2 ; A-ECG tracing of the presentation showing “Wavy triple sign” in Leads: I, II, III, aVF , aVR , and V1-6. B-ECG tracing was done after calcium injection showing the disappearance of the previous sign. ( Red arrows =elevated beats, blue arrows = isoelectric beats, and black arrows =depressed beat).

11. Case No. 2 A 26-year-old married Egyptian housewife female patient presented to the POC with carpopedal spasm and psychogenic HVS . The patient gave a recent history of poor nutritional status due to poor status . One Ca gluconate amp 10 ml 10% over IV over 10 minutes was taken. Complete clinical and ECG recovery ( Figure 3 ).

12. Figure 3 ; A-ECG tracing of the presentation showing “Wavy triple sign” in: II, III, aVF , and V6 Leads . B-ECG tracing was done after Ca injection showing the disappearance of the previous sign. ( Red arrows =elevated beats, blue arrows = isoelectric beats, and black arrows =depressed beat).

13. Case No. 3 A 63-year-old married Egyptian male farmer patient presented to the ED with carpopedal spasm. The patient gave a recent history of poor nutritional status due to deprivation . The patient was admitted in the internal ward as tetany. Two Ca gluconate ampoules 10 ml 10% over IV over 20-minutes were taken. Complete clinical and ECG recovery ( Figure 4 ).

14. Figure 4 ; A-ECG tracing of the ED presentation showing “Wavy triple sign” in: I, II, aVF , aVR , aVL , and V4 Leads . B-ECG tracing of IW copy was done before Ca++ administration showing movable changes of the wavy sign in II, III, aVL , aVF , and V6 Leads. C-ECG tracing was done after Ca injection showing the disappearance of the previous sign ( Movable phenomenon ). ( Red arrows =elevated beats, blue arrows = isoelectric beats, and black arrows =depressed beat).

15. Case No. 4 A 30-year-old married Egyptian housewife female patient presented to the ED with carpopedal spasm and psychogenic HVS . The patient gave a recent history of socio-familial stress. The patient was admitted to the IW as tetany. Two Ca gluconate ampoules 10 ml 10% over IV over 20 minutes were taken. Complete clinical and ECG recovery ( Figure 5 ).

16. Figure 5 ; A -ECG tracing of the ED presentation showing “Wavy triple sign” in V1-4 Leads . B-ECG tracing was done after Ca injection showing the disappearance of the previous sign. ( Red arrows =elevated beats, blue arrows = isoelectric beats, and black arrows =depressed beat).

17. Case No. 5 A 42-year-old married Egyptian housewife female patient presented to the POC with carpopedal spasm and psychogenic HVS . The patient gave a recent history of socio-familial stress. The patient was admitted to IW as tetany. One Ca gluconate ampoule 10 ml 10% over IV over 10 minutes was taken. Complete clinical and ECG recovery ( Figure 6 ).

18. Figure 6 ; A-ECG tracing of the POC presentation showing “Wavy triple sign” in V3, V4, and V6 Leads . B-ECG tracing was done after Ca injection showing the disappearance of the previous sign. ( Red arrows =elevated beats, blue arrows = isoelectric beats, and black arrows =depressed beat).

19. Case No. 6 A 37-year-old married, housewife, female, Egyptian patient presented to the ED with choking, rapid difficult breathing, inability speaking, and a sense of suffocation . She was recently exposed to socio-familial stress . The patient was admitted to the IW as tetany, laryngospasm, and severe hypocalcemia . Two Ca gluconate ampoules (10 ml 10% over IV over 20 minutes) were given as an emergency dose. Maintenance therapy with IVI Ca gluconate ampoules (10% with the rate; 0.5 mg/kg/hour over IV over 6 hours) was the infused ( Figure 7 ).

20. Figure 7 ; A-ECG tracing of the POC presentation showing NSR with widespread Wavy triple sign of hypocalcemia in ten leads of ECG with VR; 82 bpm. B-ECG tracing was taken within 1.30 hours after 2 amp of IV calcium therapy showing nearly normalization of all above ECG findings. ( Red arrows =elevated beats, blue arrows = isoelectric beats, and black arrows =depressed beat).

21. Case No. 7 A 30-year-old married Egyptian housewife female patient presented to the ED with carpopedal spasm and psychogenic HVS . The patient gave a recent history of socio-familial stress. The patient was admitted to the ICU as tetany with chest pain. TwoCa gluconate ampoules 10 ml 10% over IV over 20 minutes were taken. Complete clinical and ECG recovery ( Figure 8 ).

22. Figure 8 ; A-ECG tracing of the ED presentation showing “Wavy triple sign” in V1-6 Leads . depressed beats). B-ECG tracing was done after Ca injection showing the disappearance of the previous sign. ( Red arrows =elevated beats, blue arrows = isoelectric beats, and black arrows =depressed beat).

23. Case No. 8 A 58-year-old married Egyptian male carpenter patient presented to the ED with carpopedal spasm. The patient gave a history of liver cirrhosis with HCC and malnutrition . The patient was admitted to the IW for both tetany and chronic liver disease . One Ca gluconate amp 10 ml 10% over IV over 10 minutes was taken. Complete clinical and ECG recovery ( Figure 9 ). Management of CLD was given according to the standard guidelines.

24. Figure 9 ; A-ECG tracing of the ED presentation showing “Wavy triple sign” in V3, V4, and V6 Leads . B-ECG tracing was done after calcium injection showing the disappearance of the previous sign-in V4 and V6. But there is an artifact in V3, So, the author can’t decide the effect. ( Red arrows =elevated beats, blue arrows = isoelectric beats, and black arrows =depressed beat).

25. Case No. 9 A 75-year-old married Egyptian female housewife patient was admitted to the ICU with a CVA with infarction, HTN, and HVS. One Ca++ gluconate ampoule 10 ml 10% over IV over10 minutes was taken. Electrolytes profile and ABG were checked during HVS episodes. Complete resolution of the ECG changes had happened ( Figure 10 ).

26. Figure 10 ; A and B-ECG tracing during hyperventilation episodes showing “Wavy triple sign” in: II, III, aVF , and V4-6 Leads . C-ECG tracing was done after CA injection showing the disappearance of the previous sign. ( Red arrows =elevated beats, blue arrows = isoelectric beats, and black arrows =depressed beat).

27. Case No. 10 A 29-year-old married housewife Egyptian female patient presented to the POC with perioral parethesia , extremities tingling, non-specific chest pain, and fatigue. The patient gave a recent history of poor nutritional status due to heavy work. Trousseau and Chvostek's signs sign were elicited . The patient was managed with an oral Ca capsule (600 mg, single daily dose). The ECG was done within 3 days of being given oral calcium . Complete resolution of both clinical and ECG changes had happened ( Figure 11 ).

28. Figure 11 ; A-ECG tracing of the presentation showing “Wavy triple sign” in: V2, V5, and V6 Leads . B-ECG tracing was done 3 days after oral calcium showing the disappearance of the previous sign. ( Red arrows =elevated beats, blue arrows = isoelectric beats, and black arrows =depressed beat).

29. The study data and statistics Table 2 : Summary of the history, clinical, and management Data for all the study cases. * (no follow up with ECG), Addict ** ; Marijuana, BP; Blood Pressure, Ca; Calcium, CLD; Chronic liver diseases, CVA; Cerebrovascular Accident , DKA; Diabetic ketoacidosis, ECG; Electrocardiography, F; Female , HVS; Hyperventilation syndrome, K+; Potassium , Mg++; Magnesium, M; Male, Malnut : Malnutrition, Na+; Sodium, Pregn .; Pregnancy, RA; Risk factor, RR; Respiratory rate

30. Table 3 : Laboratory data for the cases of the first group ABG ; arterial blood gases, BP; blood pressure, Ca++; calcium, CLD; chronic liver disease, CVA; cerebrovascular accident, D; deficiency, DKA; diabetic ketoacidosis; diagnosis, HR; heart rate , HVS; hyperventilation syndrome, MA ** :metabolic acidosis, Na+; sodium K+; potassium, Mg++; magnesium, RR; respiratory rate, RA; respiratory alkalosis, RBS; random blood sugar

31. Some statistics Age • Age averages in the study ; Mean : 38.4, Median: 33, Mode: 30. Sex • Sex in both groups: Female (F) 72.97% (27 cases) vs. Male (M) 27.03% (10 cases)  

32. 3. Complaints • The main complaints in the study were carpopedal spasm (89.19 %) vs. Parathesia and tingling (8.11%), and hyperventilation syndrome (2.7%) ( Figure 12 ). Figure 12- showing the main complaints in the study.

33. 3.The associated risk factors (RF) and etiology • The associated risk factors (RF) and etiology in the study ; • HVS: 45.95% (17 cases) • Malnutrition: 24.32% (9 cases) • Combined RF: • Malnutrition + CLD: 5.41% (2 cases) • Malnutrition + Elderly: 2.7% (1 case) • HVS+ DKA: 2.7% (1 case) • HVS+ Coffee: 5.41% (2 cases) • HVS+ CVA: 2.7% (1 case) • HVS+ Pregnancy: 5.41% (2 cases) • HVS+ Marijuana: 2.7% (1 case) • DKA+ CLD: 2.7% (1 case) ( Figure 13 ). Figure 13; showing the associated risk factors (RF) and etiology in the study.

34. 4. The final diagnosis • Manifested tetany: 89.19% (33 cases) • Latent tetany: 8.11% (3 cases) • Non-classif ied (During cerebrovascular accident ): 2.7% (1 case) ( Figure 14 ). Figure 14 - showing the final diagnosis for hypocalcemia in the study.

35. 5.Positivity and Wavy triple sign • The wavy triple sign is a positive and triple sign in 97.3% (36 cases) but it is only wavy double in 2.7% (case No. 13). So, the percent of the sign in the study in both groups: 97.3% wavy triple (36 cases) vs. 2.7% of wavy double (one case; case No. 13) 6.Number of affected ECG leads • Averages number of affected ECG leads ( No. of leads ) ; Mean: 4.13, Median: 3, Mode: 3, Max: 10, Min: 1.

36. The frequency for the number of affected ECG leads Figure 15 - showing the frequency for the number of affected ECG leads in the study .

37. Mechanisms of Wavy triple sign   • The mechanisms of Wavy triple sign are unknown • The wavy movements in the myocardium or coronaries during tetany have suggested an explanation. These need further investigations.

38. Differential Diagnosis (DD)   • Coronary artery spasm (CAS) and IHD are possible differential diagnosis. But, in CAS and IHD; all beats of affected lead either regular depressed ST-segments or regular elevated ST-segments.

39. Management of Wavy triple sign • Essential points are considered in the management of Wavy triple sign • Serial ECG tracings • The risk • The course • The clinical status • Wavy triple sign can be treated as a case by case according to the above considerations.

40. Summary • The principles of “Wavy triple an electrocardiographic sign (Yasser sign) in hypocalcemia” and their interpretations are depending on the following: • Different subsequent three beats in the same lead are involved. • Different leads may be affected. • Mostly, there is no sharing part among the involved leads. The author intended that is not conditionally included an especial coronary artery for the affected leads. • An associated elevated beat is seen with the first of the subsequent three beats, depressed beat with the second beat, and isoelectric ST segment in the third one. • The elevated beat is either associated with ST-segment elevation or just elevated beat above the isoelectric line. Also, the depressed beat is either

41. associated with ST-segment depression or just a depressing beat below the isoelectric line. • The arrangement for depressions, elevations, and isoelectricities of ST-segment for the subsequent three beats are variable from case to case. So, this arrangement is non-conditional. • The wavy curve for the subsequent three beats from depressions, elevations, and isoelectricities are noticed and prescribed ( Figure 1 ). • The wavy movements in the myocardium or coronaries during tetany have suggested an explanation. These need further investigations. • Variable but segmental ECG leads are involved. • The extent and severity of ECG changes are related to serum calcium level in the investigated group. • Tetany and latent hypocalcemia are included. Manifested tetany was the commonest final diagnosis (89.19 %). • Hyperventilation syndrome (45.95%) and malnutrition (24.32%) are the most common risk factors.

42. • Carpopedal spasm was the main complaint (89.19 %). • Mean number of affected electrocardiographic leads: 4.13, Max.:10, and Min.:1). • Dramatic improvement of both clinical manifestation and the new electrocardiographic sign simultaneously after calcium replacement had happened. • Parenteral or oral calcium preparation was supplied. • “Wavy triple an electrocardiographic sign” is a novel sign in hypocalcemia not recorded before. • “Wavy triple an electrocardiographic sign” is a novel specific diagnostic ECG sign for hypocalcemia if compared with the old traditional non-specific ECG signs. • “Wavy triple sign” is a positive and triple sign in 97.3% (36 cases) but it is only double in 2.7% (1 case). • “Wavy triple electrocardiographic sign” can be used as a therapeutic guide in cases of hypocalcemia.

43. • Coronary artery spasm (CAS) is a possible differential diagnosis. But, in CAS; all beats of affected lead either regular depressed ST-segments or regular elevated ST-segments.   Acknowledgment   I wish to thank Ahmed Alghobary , B.sc. for his technical support.

44. Conclusion and Recommendations   • “Wavy triple an electrocardiographic sign (Yasser’s sign) ” is a new specific diagnostic sign seen in 97.3% of the cases of hypocalcemia. • “Wavy triple an electrocardiographic sign” can be used as a therapeutic guide in the cases of hypocalcemia. • Further investigations for the “Wavy triple an electrocardiographic sign (Yasser sign)” for more evaluation and assessment are recommended.  

45. References   1. Elsayed YMH . Wavy Triple an Electrocardiographic Sign (Yasser Sign) in Hypocalcemia. A Novel Diagnostic Sign; Retrospective Observational Study. EC Emergency Medicine and Critical Care (ECEC). 2019;3(2):1-2. Available from: https://www.ecronicon.com/ecec/volume3-issue12.php (Accessed Nov 6, 2019). 2. Elsayed YMH . Hypocalcemia-induced Camel-hump T-wave, Tee-Pee sign, and bradycardia in a car-painter of a complexed dilemma: A case report. Cardiac 2020;2(1):07. DOI : https://doi.org/10.35702/card.10007  

46. Thank you