ECG changes in hyperkalemia

Hyperkalaemia causes a rapid reduction in resting membrane potential, leading to increased cardiac depolarisation and muscle excitability, which in turn causes ECG changes (1).

ECG changes are usually progressive and may include:

• tall, peaked (tented) T waves [T wave larger than R wave in more than 1 lead]
• first-degree heart block (prolonged PR interval) [>0.2 s];
• flattened or absent P waves
• ST-segment depression
• S and T wave merging (sine wave pattern)
• widened QRS [>0.12 s]
• arrhythmias including bradycardia, ventricular tachycardia or fibrillation
• cardiac arrest (pulseless electrical activity [PEA], ventricular fibrillation/pulseless ventricular tachycardia [VF/VT], asystole) (2)

ECG changes with hyperkalaemia do not consistently follow a stepwise, dose-dependent pattern.

• risk of arrhythmias increases with potassium values > 6.5 mmol/L, and even small elevations in potassium above this concentration can lead to rapid progression from peaked T waves to ventricular fibrillation or asystole
• the longer a patient has high potassium concentrations, the greater the risk of sudden deterioration (1)

Click here for an example ECG and further information

Note:

• ECG findings are neither specific nor sensitive for detecting hyperkalaemia (3)

References:

1. UK Kidney Association. Clinical Practice Guidelines - Management of Hyperkalaemia in Adults. October 2023.
2. Lott C et. al. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. Resuscitation. 2021 Apr;161:152-219. doi: 10.1016/j.resuscitation.2021.02.011.
3. Nyirenda MJ et al. Hyperkalaemia. BMJ. 2009;339:b4114.