J Wave Research Articles

Osborn wave in patients with ST-elevation myocardial infarction undergoing mild therapeutic hypothermia after cardiac arrest

Objective Experimental and clinical studies have proven the neuroprotective effects of hypothermia in unconscious patients with spontaneous circulation after out-of-hospital cardiac arrest. Based on this evidence, recommendations have been made to incorporate mild therapeutic hypothermia into practice. ECG changes are well documented in people with incidental hypothermia but there are only few studies on ECG abnormalities in patients undergoing mild therapeutic hypothermia after cardiac arrest due to ST-elevation myocardial infarction.Methods Ten patients with ST-elevation myocardial infarction (STEMI) complicated by cardiac arrest and receiving mild therapeutic hypothermia (MTH) after return of spontaneous circulation and ten comparable patients but not receiving mild therapeutic hypothermia as a control group were incorporated into our prospective study. We analysed electrocardiographic (ECG) changes during hypothermia and its influence on ECG evolution in patients after STEMI.Results MTH was mainly associated with decrease of heart rate (P = 0.014) and QTc interval prolongation (P = 0.005). In 60% of patients the Osborn wave was registered. The presence of a new Q wave or new negative T wave in ECGs registered on the 3rd day of STEMI was comparable in the two groups.Conclusions Although hypothermia is associated with typical ECG findings like Osborn wave, the electrocardiographic evolution of STEMI in patients receiving MTH is comparable with that in patients without it.

The correlation between the amplitude of Osborn wave and core body temperature.

Several reports illustrate an inverse correlation between the Osborn wave (J wave) amplitude and core body temperature. We attempted to study the strength of this correlation. We reviewed all articles reporting hypothermic J waves from 1950-2014 for patient demographics, core body temperature in Celsius (°C), amplitude of the J wave in millimeters (mm), lead with the highest amplitude of J wave, presence of acidosis, PO2, electrolytes and outcome. In cases with more than one electrocardiogram (ECG), the respective core body temperature and J wave amplitude of each ECG were recorded. The main study outcome is to evaluate the correlation between the J wave amplitude and core body temperature in the admission ECG. We have also examined the strength of this relationship in cases with more than one ECG. We attempted to find the most frequent lead that recorded the highest amplitude of the J wave in addition to the correlation between the amplitude of J wave and pH. We found 64 articles comprising a total of 68 cases. When analyzing only cases with more than one reported ECG, there was a strong inverse correlation (r = - 0.682, p<0.001) between J wave amplitude and body temperature: however, when analyzing admission ECG of all cases, the correlation was only moderate (r = - 0.410, p<0.001). The lead with the highest amplitude of the J wave was V4 (44% of the cases, p<0.001) followed by V3 (23.7% of the cases, p<0.001). The amplitude of the J wave in the admission ECG of hypothermic patients may not accurately predict the core body temperature.

Cardiac arrest due to accidental hypothermia—A 20 year review of a rare condition in an urban area

BackgroundAccidental hypothermic cardiac arrest is associated with unfortunate prognosis and large studies are rare. We therefore have performed an outcome analysis in patients that were admitted to Vienna University Hospital with the diagnosis of accidental hypothermic cardiac arrest. MethodsThis study employed a retrospective outcome analysis of prospectively collected data in a selected cohort of hypothermic cardiac arrest patients. We screened 3800 cardiac arrest patients, treated at our department between 1991 and 2010, for eligibility. Inclusion criteria were cardiac arrest with a body core temperature ≤28°C and return of spontaneous circulation. ResultsA total of 18 patients who achieved return of spontaneous circulation were analysed. Nine patients (50%) achieved survival in good neurologic condition (defined as cerebral performance category CPC 1 or 2). Accidental hypothermia with consecutive cardiac arrest was caused by intoxication in most cases (67%). These patients had a better outcome than patients with other causes of accidental hypothermic cardiac arrest (OR=28; 95%KI 2–37.9; p<0.01). Hypothermia associated typical ECG changes after return of spontaneous circulation (Osborne waves) were more frequent in the surviving population (OR 16; 95%KI 1.3–19.5; p=0.05). ConclusionsAccidental hypothermic cardiac arrest in a central European urban area is rare. Prognosis was excellent in patients where hypothermic cardiac arrest was caused by intoxication.

Giant J-wave and Brugada-like pattern in a patient with severe hypothermia

We describe a patient with severe hypothermia, in whom the electrocardiogram showed giant J-waves, also known as Osborn waves, distinguishable in the inferior and anterolateral leads. Moreover, a Brugada-like pattern was also visible in leads V2 and V3. The presented case and ECG findings may contribute to the discussion about the pathophysiologic mechanism underlying Brugada syndrome and giant J-wave.

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Introduction: Hypothermia remains a challenging clinical problem in US. Causes of hypothermia include cold exposure, medical condition such as hypothyroidism, adrenal insufficiency, sepsis, toxin, and medications. Hypothermia is also complicated by other comorbidities such as arrhythmia, lactic acidosis, coagulopathy, infection, and rhabdomyolysis which are life threatening. This can explain high mortality rate of this condition (40%). We present a case of hypothermia as a presentation of hypothyroidism. 74-year-old Hispanic female was brought to the ER as Jane Doe after she was found unresponsive on the street. At ER, she was alert but confused. Medical history was not available at that time. On examination, there were multiple abrasions on extremities. Vital signs were as follows: rectal temerature 28.1 c, blood pressure 122/67 mmHg, heart rate 78/min, respiration 14/min, and oxygen saturation 100% on room air. Her examination was notable for dry mucous membranes, very cold and moist skin, irregular heart rhythm, pupils 3 mm sluggishly reacted to light, and her GCS score was 10. EKG demonstrated atrial fibrillation rate of 93/min with prominent Osborne waves. Active rewarming process was initiated immediately by warm IVF, Bair hugger, bladder irrigation with warm saline, and warmed humidified air. Thirty minutes later, she was more responsive but her blood pressure dropped to 88/52 mmHg and temperature was 30 c. EKG was same as previous. She receives 3 L of NS as bolus and was started on vasopressor. Empiric antibiotics were given. She was then monitored closely in MICU. Laboratory revealed the following results: pH 7.28, pCO2 59, pO2 136, bicarbonate 29, sodium 139, potassium 2.7, creatinine 1.02, lactic 4.5, troponin I 0.05, CPK 869, urine myoglobin < 1, d-dimer 5.41, WBC 14.5, TSH 14.378 mcunit(high), free T4 0.9 ng/dL(normal), cortisol 40, urine drug screen - negative, ammonia 31. CT brain and CT chest was negative for any intracranial lesion and pulmonary embolism. Cardiology was consulted for elevated troponin and possible myocardial infarction. Echocardiography revealed no wall motion abnormality. Elevated troponin was likely reflect rhabdomyolysis. Endocrinology thought that myxedema coma was less likely and recommended to start patient on levothyroxine 50 mcg daily without loading dose for treatment of hypothyroidism. Later on that day, Her son was successfully contacted by hospital and gave information that patient has hypertension, dyslipidemia and worsened memory loss in the past 2 months. After 6 hours of rewarming process, the core temperature normalized (37.1 c). Her EKG converted to normal sinus rhythm. During the hospital course, her CPK trending up to 5,324 then trending down with aggressive IV fluid while her kidney function was maintain normal. Neurological investigations were done reveal normal MRI brain, normal EEG, normal level of vitamin B12. Neurologist confirmed diagnosis of dementia likely secondary to hypothyroidism. She was transferred to general floor at 48 hours. Her consciousness improved back to baseline at 72 hours and was discharged on the sixth day in good condition on levothyroxine 50 mcg oral daily. There are various causes of hypothermia. In this case, it was possible to assume that this patient who was hospitalized with hypothermia and altered mental status suffers from hypothyroidism. The acute decompensation of hypothyroidism is typically precipitated by environment cold exposure, infection, medication or withdrawal. In patients suspected to have this condition, the passive rewarming is preferred compared to active rewarming which carries risk of vasodilation and hypotension which happened in our patient. Our patient also had sign of hypothyroidism (dementia) preceding this incidence. This should raise importance of checking TSH as a routine work up in dementia for early diagnosis and treatment to prevent patient from myxedema coma which has high mortality rate.

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Introduction: Hypothermia is a known side effect of atypical antipsychotic drugs which generally resolves following discontinuation of the offending agent. We report a case of refractory hypothermia leading to death in a patient taking risperidone for treatment of schizophrenia. A 67-year-old man presented to our ED with hypothermia and delirium after being found stuperous at a nursing facility. He had been at baseline until 14 days prior to presentation when temperature was noted to be 88°F. Hypothermia persisted despite discontinuation of risperidone and initiation of olanzapine. Past medical history included schizophrenia, HIV (CD4: 398), and gout. There was no history of thyroid disease or ambient exposure. Vital signs were temperature 86.4°F, pulse 69, and respiratory rate 37. He was minimally responsive to painful stimuli. Neurologic exam was non-focal. Pertinent work-up showed: creatinine 2.6, TSH 5.7, cortisol 28, and pancytopenia. CXR showed pleural effusions. EKG was negative for Osborn waves. Head CT, CSF, BAL, blood, and urine cultures were all negative. Hypothermia persisted despite use of external warming device and discontinuation of olanzapine. On hospital day 2, he became hypotensive and was transferred to the ICU where antibiotics and vasopressors were initiated. On hospital day 7, he had two PEA arrests and care was withdrawn. Severe hypothermia, although a rare and usually benign side effect of antipsychotics, is the most likely diagnosis in this case given that ambient exposure, long-standing thyroid disease, adrenal insufficiency, and sepsis were all ruled out as inciting factors. To our knowledge, there have been 129 reported cases of risperidone-induced hypothermia. This case stands out because of the poor outcome. Risperidone is renally cleared and our patient's impaired kidney function likely increased his risk for side effects. Prescribers should be aware of the adverse effects of risperidone and discontinue antipsychotics at onset of hypothermia.

About hypothermal J wave

About hypothermal J wave

Classic Osborn waves and incessant ventricular fibrillation in severe hypothermia

Cardiac arrhythmias in severe hypothermia are common and are managed primarily by re-warming techniques. A 64-year-old male presented with alcohol associated aspiration pneumonia, sepsis and severe hypothermia and was noted to have classic ECG changes of hypothermia, i.e. Osborn waves. The patient had a tumultuous clinical course with prolonged resuscitative measures. Ultimately, an early focus on invasive core temperature re-warming with cardio-pulmonary bypass resulted in a favorable outcome.

Long QT interval in a patient after out-of-hospital cardiac arrest with hypocalcaemia, undergoing therapeutic hypothermia

A 53-year-old woman was hospitalized after out-of-hospital cardiac arrest due to ventricular fibrillation. Initial electrocardioagram showed sinus rhythm of 117 beats per minute, 452 ms QTc interval, ST-segment depression up to 1 mm in V(2)-V(6), and ST-elevation in lead aVR. Patient was treated with primary coronary angioplasty and therapeutic hypothermia, during which QTc interval prolonged up to 616 ms and Osborn wave was seen in lead V(4), along with elevation of ST-segment in I, II, III, aVF, V(5) and V(6); negative T waves in I, II, aVL, aVF, and V(2)-V(6). Laboratory test results showed hypocalcaemia. After rewarming and ion correction QT abnormalities resolved.

Himalayan Osborn Waves

A 57-year-old man with history of polysubstance abuse was found in the snow in an intoxicated state by emergency medical services personnel. On arrival, his rectal temperature was 81 F and the rest of the physical examination was consistent with hypotension, bradycardia, and somnolence. His electrocardiogram (ECG) showed atrial fibrillation, tremor artifact, wide QRS, prolongation of PR and QT interval, and giant Osborn waves (Fig. 1, arrows). Initial laboratory data was consistent with anion-gap (lactic) metabolic acidosis and rhabdomyolysis. Serum and urine toxicology screens were positive for ethanol and opiates, respectively. After rewarming with an external rewarmer and warm intravenous fluids, repeat ECG showed normal sinus rhythm and decreased Osborn wave amplitude at a temperature of 89 F (Fig. 2A), followed by complete normalization after restoration of normothermia (Fig. 2B). Electrocardiographic J (or Osborn) waves are typically known to be associated with hypothermia, however, rarely can be seen in other conditions like head injury, subarachnoid hemorrhage, hypercalcemia, cardiac ischemia, cocaine use, and haloperidol overdose. Apart from these conditions in which discrete J-waves can be readily distinguished, J-waves can often be partially buried in the R wave in benign early repolarization, manifesting as J-point or ST segment elevation and terminal slurring of QRS. Recent evidence has suggested that arrhythmias associated with an early repolarization pattern in the inferior or mid to lateral precordial leads,

Electrocardiographic changes in hypothermia: a review.

Hypothermia is a common environmental emergency encountered by physicians and is associated with a variety of electrocardiographic (ECG) abnormalities. The classic and well-known ECG manifestations of hypothermia include the presence of J (Osborn) waves, interval (PR, QRS, QT) prolongation, and atrial and ventricular arrhythmias. There are less well defined and known ECG signs of hypothermia, which in fact may simulate findings of acute coronary ischemia, Brugada syndrome, or even pericarditis. Although classical ECG changes seen in hypothermia certainly serve as an important clinical clue for prompt identification and management of this easily curable life-threatening entity, physicians should, however, be able to maintain a high suspicion for recognition and differentiation of less common ECG abnormalities encountered in hypothermia. This article aims to provide a detailed review of all the potential ECG abnormalities that may be encountered in accidental and iatrogenic hypothermia.

Drowning, Hypothermia and Cardiac Arrest: An 18-year-old Woman with an Automated External Defibrillator Recording

This report describes the case of an 18-year-old woman who was found in the sea suffering from cardiac arrest and hypothermia, 90 minutes after she entered the water to swim. The rescue team used an automated external defibrillator to record prehospital management. This recording showed an isoelectric electrocardiogram followed by a ventricular fibrillation, an unsuccessful defibrillation, and lastly, a return of spontaneous circulation with Osborn wave. When she was admitted to the intensive care unit two hours later, the woman's central temperature was 28°C. The case is interesting because of several points. First, to the best of the authors' knowledge, this is the only case of cardiac arrest with severe hypothermia followed by a return of spontaneous circulation documented with an automated external defibrillator recording. Second, the hypothermia is an atypical case occurring in the summer. Hypothermia must be considered even in unlikely circumstances, such as summer in the south of France, when ambient temperatures are high. Lastly, after three days, the patient recovered successfully from cardiopulmonary arrest without cerebral dysfunction.

Osborn waves in a patient with hypothermia due to severe hypothyroidism

An 88-year-old female with history of hypothyroidism was brought to our emergency department with acute change in mental status. Her vital signs were significant for a core body temperature of 88°F (31°C). She was found to be severely hypothyroid (serum TSH—7.14 mU/l, Free T4—0.5 ng/dl) …

Severe Hypothermia in Parkinson's Disease

Hypothermia has been reported in many clinical states and sometimes it is life threatening. However, there are rare cases reported about hypothermia related with Parkinson's disease (PD) 1, 2, 3. We now present a patient with PD, who developed an episode of severe hypothermia. The unique changes both in electrocardiogram (ECG) and in electroencephalogram (EEG) during hypothermia were presented and discussed.

Giant J-wave (Osborn wave) related to hypothermia and hypokalemia

Giant J-wave (Osborn wave) related to hypothermia and hypokalemia

The Osborn wave, not just for cardiologists!

The Osborn wave, named in the honor of John Osborn after his elegant work in 1953 1, is well known to cardiologists. It manifests as a deflection at the R-ST junction of the ECG, is usually more evident in the inferior and lateral leads 2, and has an amplitude that is inversely correlated with the core body temperature 3 (Fig. 1). It is the result of a transient, outward, potassium-mediated current in the ventricular epicardium, but not in the endocardium, creating a transmural voltage gradient during early repolarization that is reflected as the J wave. Although characteristic of hypothermia, there are other nonhypothermic precursors for Osborn waves, including severe hypercalcemia 4, subarachnoid hemorrhage 5, myocardial ischemia 6, Brugada syndrome 7, and following cardiac resuscitation 8.Fig. 1: (a) ECG of a head trauma victim recorded at a temperature of 36°C revealing sinus bradycardia, 55 beats/min without evident J waves. (b) ECG recorded at 29.6°C revealing sinus bradycardia, 48 beats/min; prolonged PR interval at 0.24 s, prolonged QRS interval at 0.16 s, a corrected QT interval of 0.5 s, and classic high-amplitude J waves. Reproduced from Omar and Abdelmalak3 with permission and modification from the Cleveland Clinic Foundation, ©2011 The Cleveland Clinic Foundation. All rights reserved.Osborn waves can be encountered in stroke units and neurocritical care, where patients are at times offered therapeutic hypothermia for its neuroprotective role. Mild to moderate hypothermia has been found to reduce ischemic brain edema in the setting of massive ischemic strokes 9,10. Therapeutic hypothermia has also led to a better outcome in patients with aneurysmal subarachnoid hemorrhage 11. Another valuable use of the Osborn wave for neurologists and neurosurgeons is its ability to raise suspicion for brain death in cases with severe head trauma after the exclusion of other hypothermic causes. An important clue is provided when the Osborn waves are unaccompanied by shivering artifacts in the ECG (and the patient is not on any sedation). In brain death, the Osborn wave is attributed to hypothermia because of the impaired thermoregulatory ability resulting from hypothalamic dysfunction 12. ICU physicians are widely exposed to the Osborn wave in their daily practice mostly as a consequence of therapeutic hypothermia frequently attempted to improve the neurological outcome in postcardiopulmonary resuscitation patients. Other causes for encountering the Osborn wave in the ICU include sepsis 13, alcohol consumption, drug intoxication 14, and cardiac arrest 8. Anesthesiologists encounter hypothermic patients in cases of cerebral aneurysm surgery when therapeutic hypothermia is occasionally utilized 15 or because of inadvertent core hypothermia that is often observed in the immediate postoperative period especially in the elderly and high-risk surgical patients secondary to the effects of anesthesia 16,17. Emergency room physicians are also exposed to the Osborn waves through a variety of clinical presentations including multitrauma patient 18, submersion 19, and exposure to cold weather 20. Endocrinologists can encounter the Osborn wave in certain scenarios. Sheikh and Hurst 21 reported the occurrence of Osborn waves in a patient with diabetic ketoacidosis-induced severe hypothermia. Hypercalcemia is another endocrinal cause for the Osborn waves. Otero and Lenihan 4 reported the occurrence of Osborn waves in a nonhypothermic patient because of hypercalcemia resulting from a parathyroid adenoma. Sridharan and Horan 22 reported the occurrence of Osborn waves in two hypercalcemic patients secondary to malignancy. Hypothermia can also be encountered in patients with anorexia nervosa 23 and malnutrition 24,25. Other endocrinal causes of hypothermia include hypothyroidism, hypopituitarism, and hypoadrenalism. Interestingly, in most instances, the physicians likely to encounter the Osborn wave work in the emergency room, ICU, operating room, or stroke units, rather than as cardiologists. Identification of Osborn waves has several clinical implications. In most instances, it is a marker of severe hypothermia and a sign of overcooling 26 that is associated with various complications including hemodynamic instability. The Osborn wave has a poor prognostic significance, where it is found to be a precursor for the occurrence of ventricular fibrillation 27. The presence of the Osborn wave unaccompanied by shivering artifacts in the surface ECG provides a clue to raise a suspicion for brainstem death in head trauma victims after exclusion of other causes of hypothermia. We aim to emphasize the importance of recognizing the Osborn wave and its implications among the various specialities expected to encounter it and not just cardiologists. Acknowledgements Conflicts of interest There are no conflicts of interest.

Hypothermia masquerading as pericarditis: an unusual electrocardiographic analogy

Hypothermia is one of the most common environmental emergencies encountered by physicians that can be associated with a variety of electrocardiographic (ECG) abnormalities. The classic and well-known ECG manifestations of hypothermia include the presence of J (Osborne) waves, interval (PR, QRS, QT) prolongation, varied T-wave abnormalities, and atrial and ventricular arrhythmias. There are less well-defined and known ECG signs of hypothermia that, in fact, may simulate findings of acute coronary ischemia. We describe a case of hypothermia with associated ECG findings mimicking pericarditis. Especially interesting was the challenging presentation and several associated important learning points. Herewith, we also discuss some important ECG and clinical factors that may be used in differentiating the genesis of ST elevations.

Osborn Wave in a Patient with Intracranial Haematoma and Hypothermia

Hypothermia is defined as a core body temperature below 35°C. Hypothermia affects all organs, especially the brain and heart. Osborn wave (J) is a positive deflection that is seen at the end of the QRS wave in electrocardiography (ECG) and could be seen in cases such as intracranial events, and hypercalcemia besides hypothermia. An 85-year-old male patient was found unconscious in cold weather. He was hypothermic and J wave was detected in his ECG examination. His brain CT scan revealed intracerebral haematoma. Our aim is to reiterate that intracranial haemorrhage can be a differential diagnosis for patients who come to the emergency department with hypothermia and Osborn wave in ECG.

Hypotermia in the elderly

IntroductionAn 88-year-old woman suffered a cerebrovascular accident and was found on the floor of her cold house.Materials and methodsAt the time of admission to our division, the patient was unresponsive with a rectal temperature of 28 °C, blood pressure of 120/80 mmHg, and a heart rate of 40 bpm. The cerebral CT revealed a hypodense lesion in the temporal region. The ECG showed sinus bradycardia, prolonged PR and QTc intervals, and a classic “J” (Osborn) wave that was most pronounced in the lateral and inferior leads. The patient presented a low respiratory rate, hypoventilation, severe acidosis (both respiratory and metabolic), hyperkalemia, elevated liver enzymes, mild anemia, hyporeflexia, and sluggish pupil responses.ResultsDuring rewarming with thermic blanket and heated intravenous fluids, the respiratory condition improved, and the ECG alterations disappeared. Twenty-four hours later, however, the patient died suddenly due to cardiac asystole.DiscussionThis report analyses the effects of hypothermia and its clinical manifestations and provides a brief discussion of the electrophysiologic mechanisms underlying Osborn waves and the other electrocardiographic changes associated with hypothermia.

Electrocardiographic changes in therapeutic hypothermia

IntroductionDuring therapeutic hypothermia (TH), electrocardiographic (ECG) abnormalities such as Osborn waves and/or ST-segment elevation have been described. However, the incidence and prognostic value of these ECG changes are uncertain given the small-scale studies that have been carried out to date. The aim of this study is to further evaluate the electrocardiographic changes during TH.MethodsDuring a period of 3 years, 81 patients (age 63 ± 14 years) were included retrospectively. All patients underwent TH after being resuscitated. ECG registrations before, during and after TH were collected and analyzed. Patients were divided into two groups based on the presence or absence of transmural ischemia ST elevation on the first representative ECG upon arrival at the hospital (ST-segment elevation myocardial infarction (STEMI) and non-STEMI).ResultsA total of 243 ECGs were analyzed. During TH 24 patients (30%) had Osborn waves, which disappeared in 22 patients (92%) after regaining normal body temperature. The presence of Osborn waves was not associated with age, gender, average pH, electrolytes, or lactate levels and was not associated with excess in-hospital mortality. In 10 patients (12%, six non-STEMI patients) new STEMI was observed during TH, which disappeared after TH discontinuation. The STEMI group (44 patients) had significantly more Osborn waves during TH than the non-STEMI group (38.6% vs. 15.2%, odds ratio = 3.508; 95% confidence interval = 1.281 to 9.610).ConclusionsHypothermia-induced Osborn waves are relatively common and are not associated with an unfavorable short-term outcome. TH is associated with ECG changes that may mimic STEMI.