Potassium is vital for regulating the normal electrical activity of the heart. Increased extracellular potassium reduces myocardial excitability, with depression of both pacemaking and conducting tissues.
Progressively worsening hyperkalaemia leads to suppression of impulse generation by the SA node and reduced conduction by the AV node and His-Purkinje system, resulting in bradycardia and conduction blocks and ultimately cardiac arrest.
- Hyperkalaemia is defined as a potassium level > 5.5 mEq/L
- Moderate hyperkalaemia is a serum potassium > 6.0 mEq/L
- Severe hyperkalaemia is a serum potassium > 7.0 mE/L
Effects of hyperkalaemia on the ECG
Serum potassium > 5.5 mEq/L is associated with repolarization abnormalities:
- Peaked T waves (usually the earliest sign of hyperkalaemia)
Serum potassium > 6.5 mEq/L is associated with progressive paralysis of the atria:
- P wave widens and flattens
- PR segment lengthens
- P waves eventually disappear
Serum potassium > 7.0 mEq/L is associated with conduction abnormalities and bradycardia:
- Prolonged QRS interval with bizarre QRS morphology
- High-grade AV block with slow junctional and ventricular escape rhythms
- Any kind of conduction block (bundle branch blocks, fascicular blocks)
- Sinus bradycardia or slow AF
- Development of a sine wave appearance (a pre-terminal rhythm)
Serum potassium level of > 9.0 mEq/L causes cardiac arrest due to:
- Ventricular fibrillation
- PEA with bizarre, wide complex rhythm
(Warning! In individual patients, the serum potassium level may not correlate closely with the ECG changes. Patients with relatively normal ECGs may still experience sudden hyperkalaemic cardiac arrest.)
ECG manifestations in hyperkalaemia
- Peaked T waves
- Prolonged PR segment
- Loss of P waves
- Bizarre QRS complexes
- Sine wave
Suspect hyperkalaemia in any patient with a new bradyarrhythmia or AV block, especially patients with renal failure, on haemodialysis or taking any combination of ACE inhibitors, potassium-sparing diuretics and potassium supplements.
For an excellent review of the management of hyperkalaemia, check out this podcast by Scott Weingart.
This ECG displays many of the features of hyperkalaemia:
- Prolonged PR interval.
- Broad, bizarre QRS complexes — these merge with both the preceding P wave and subsequent T wave.
- Peaked T waves.
This patient had a serum K+ of 9.3
- Tall, symmetrically peaked T waves.
This patient had a serum K+ of 7.0.
- Long PR segment.
- Wide, bizarre QRS.
- Slow junctional rhythm.
- Intraventricular conduction delay.
- Peaked T waves.
- Broad complex rhythm with atypical LBBB morphology.
- Left axis deviation.
- Absent P waves.
- Sine wave appearance with severe hyperkalaemia (K+ 9.9 mEq/L).
- Huge peaked T waves.
- Sine wave appearance.
This patient had severe hyperkalaemia (K+ 9.0 mEq/L) secondary to rhabdomyolysis.
- Wiesbauer F, Kühn P. ECG Yellow Belt online course: Become an ECG expert. Medmastery
- Wiesbauer F, Kühn P. ECG Blue Belt online course: Learn to diagnose any rhythm problem. Medmastery
- Rawshani A. Clinical ECG Interpretation ECG Waves
- Smith SW. Dr Smith’s ECG blog.
- Mattu A, Tabas JA, Brady WJ. Electrocardiography in Emergency, Acute, and Critical Care. 2e, 2019
- Brady WJ, Lipinski MJ et al. Electrocardiogram in Clinical Medicine. 1e, 2020
- Straus DG, Schocken DD. Marriott’s Practical Electrocardiography 13e, 2021
- Hampton J. The ECG Made Practical 7e, 2019
- Grauer K. ECG Pocket Brain (Expanded) 6e, 2014
- Brady WJ, Truwit JD. Critical Decisions in Emergency and Acute Care Electrocardiography 1e, 2009
- Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice: Adult and Pediatric 6e, 2008
- Mattu A, Brady W. ECG’s for the Emergency Physician Part I 1e, 2003 and Part II
- Chan TC. ECG in Emergency Medicine and Acute Care 1e, 2004
LITFL Further Reading
- ECG Library Basics – Waves, Intervals, Segments and Clinical Interpretation
- ECG A to Z by diagnosis – ECG interpretation in clinical context
- ECG Exigency and Cardiovascular Curveball – ECG Clinical Cases
- 100 ECG Quiz – Self-assessment tool for examination practice
- ECG Reference SITES and BOOKS – the best of the rest