ECG changes in hyperkalaemia

Last edited 02/2018 and last reviewed 10/2022

Hyperkalaemia causes a rapid reduction in resting membrane potential leading to increased cardiac depolarization, and muscle excitability which in turn causes EG 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]
• arrythmias 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 increase 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 finding are neither specific nor sensitive for detecting hyperkalaemia (3)

Reference:

• (1) UK Renal Association 2014. Clinical practice guidelines. Treatment of acute hyperkalaemia in adults  
• (2) Soar J et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation. 2010;81(10):1400-33.
• (3) Nyirenda MJ et al. Hyperkalaemia. BMJ. 2009;339:b4114.