Elektrokardiyografi‘de Sık Atlanan Bulgular

Abstract

Elektrokardiyografi (EKG), acil servislerde tanısal bir temel taşı olmasına rağmen hatalı yorumlanmaya oldukça açıktır. Zaman baskısı ve otomatik yorumlara duyulan aşırı güven, özellikle klasik STEMI kriterlerini karşılamayan ancak yüksek mortalite riski taşıyan durumların atlanmasına neden olabilir. Bu metinde; sistematik bir değerlendirme sırası (ritim, hız, aks, intervaller, ST-T ve QRS morfolojisi) önerilmektedir. Ayrıca; sinüs taşikardisinin patolojik nedenleri, aks sapmalarının klinik önemi, atriyal genişlemeler (P mitrale/pulmonale), PR mesafesi anomalileri (WPW, AV bloklar), QRS voltaj değişiklikleri (tamponat) ve hayati önem taşıyan ST-T değişiklikleri (Posterior MI, De Winter, Brugada, Wellens Sendromu) ele alınmaktadır. Klinik korelasyonun önemi vurgulanarak, elektrot hataları gibi yanıltıcı faktörlere karşı dikkatli olunması gerektiği belirtilmektedir.

Keywords

• EKG
• Acil Tıp
• Wellens Sendromu
• WPW
• Brugada Sendromu

Frequently Missed Findings in Electrocardiography

Abstract

Although electrocardiography (ECG) is a diagnostic cornerstone in emergency departments, it is highly prone to misinterpretation. Time pressure and over-reliance on automated ECG interpretations can lead to overlooking conditions that do not meet classic STEMI criteria but carry a high risk of mortality. This text suggests a systematic evaluation sequence (rhythm, rate, axis, intervals, ST-T, and QRS morphology). Furthermore, it addresses pathological causes of sinus tachycardia, clinical significance of axis deviations, atrial enlargements (P mitrale/pulmonale), PR interval anomalies (WPW, AV blocks), QRS voltage changes (tamponade), and life-threatening ST-T changes (Posterior MI, De Winter, Brugada, and Wellens Syndrome). Emphasizing the importance of clinical correlation, it highlights the need for vigilance against misleading factors such as electrode misplacements.

Keywords

• ECG
• Emergency Medicine
• Wellens Syndrome
• WPW
• Brugada Syndrome

References

1. Goldberger AL, Goldberger ZD, Shvilkin A. Goldberger’s Clinical Electrocardiography: A Simplified Approach. 10th ed. Elsevier; 2023:12-25.
2. Turnipseed SD, Trythall WS, Diercks DB, Laurin EG, Kirk JD, Smith DS, et al. Frequency of acute coronary syndrome in patients with normal electrocardiogram performed during presence or absence of chest pain. Acad Emerg Med. 2009 Jun;16(6):495-9.
3. Schläpfer J, Wellens HJ. Computer-Interpreted Electrocardiograms: Benefits and Limitations. J Am Coll Cardiol. 2017 Aug 29;70(9):1183-1192.
4. Hampton JR, Hampton J. The ECG Made Easy. 9th ed. Elsevier; 2019:45-60.
5. Kosuge M, Kimura K, Ishikawa T, Ebina T, Hibi K, Kusama I, et al. Electrocardiographic differentiation between acute pulmonary embolism and acute coronary syndromes on the basis of negative T waves. Am J Cardiol. 2007 Mar 15;99(6):817-21. et al.
6. Hancock EW, Deal BJ, Mirvis DM, Okin P, Kligfield P, Gettes LS, et al. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part V: ST, T, and U waves, and the QT interval. J Am Coll Cardiol. 2009;53(11):1003-1011.
7. Burns E, Buttner R. Life in the Fast Lane: ECG Library. Published January 15, 2022. https://litfl.com/ecg-library/. Accessed February 10, 2026.
8. Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, et al. 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2019;74(14):e51-e156.

9. Surawicz B, Knilans TK. Chou’s Electrocardiography in Clinical Practice: Adult and Pediatric. 6th ed. Saunders Elsevier; 2008:443-460.
10. Littmann L, Gibbs MA. The electrocardiogram in hyperkalemia: a systemic review. Am J Emerg Med. 2014;32(10):1264-1271.
11. Brugada J, Katritsis DG, Arbelo E, Arribas F, Bax JJ, Blomström-Lundqvist C, et al. 2019 ESC Guidelines for the management of patients with supraventricular tachycardia: The Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC). Eur Heart J. 2020;41(5):655-720.
12. O’Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, Chung MK, de Lemos JA, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61(4):e78-e140.
13. Morris NP, Body R. The De Winter ECG pattern: morphology and predictive value for acute main stem or proximal left anterior descending artery occlusion. Eur J Emerg Med. 2017;24(4):268-275.
14. Antzelevitch C, Brugada P, Borggrefe M, Brugada J, Brugada R, Corrado D, et al. Brugada syndrome: report of the second consensus conference: endorsed by the Heart Rhythm Society and the European Heart Rhythm Association. Circulation. 2005;111(5):659-670.
15. Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases. Eur Heart J. 2014;35(41):2873-2926.
16. Stone J, Mor-Avi V, Ardelt A, Lang RM. Frequency of Inverted Electrocardiographic T Waves (Cerebral T Waves) in Patients With Acute Strokes and Their Relation to Left Ventricular Wall Motion Abnormalities. Am J Cardiol. 2018 Jan 1;121(1):120-124.
17. De Zwaan C, Bär FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982;103(4 Pt 2):730-736.
18. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com/. Accessed February 10, 2026.
19. Medscape. New York, NY: Medscape LLC. https://www.medscape.com/. Accessed February 10, 2026