It's the middle of the night. The patient's spouse meets you at the front door and brings you back to the bedroom.
The patient is sitting on the edge of his bed. He is highly anxious and complaining of chest discomfort and palpitations.
Onset: During sleep
Provoke: Running made the sensation feel better earlier the previous day
Quality: An "electric" sort of "full" feeling in his chest
Radiate: The sensation does not radiate
Severity: 5/10
Time: Started earlier the previous day but went away after running
The patient takes several deep breaths during EMS evaluation and seems upset that it doesn't correct the problem.
Skin is pink, warm, and moist.
Breath sounds are clear bilaterally.
Vital signs are assessed.
RR: 20 and shallow
HR: 100
BP: 160/98
SpO2: 98 on RA
The cardiac monitor is attached.
A 12-lead ECG is captured.
And another.
What's going on here?
Could this be WPW?
Why or why not?
It's a paced rhythm. Note in leads V4 and V5 there are small pacing spikes at the commencement of the QRS? Modern pacemakers have a ring electrode a couple of mm's back from the electrode tip and this reduces the distance for the impulse to 'earth' thus creating a tiny spike.
ReplyDeleteIt is too regular and of normal rate for it to be a tachyarrhythmia and all the QRS's have the morphology of a paced rhythm. The patients discomfort is more likely related to IHD that is existing than this rhythm.
Tough EKG. This + CP = badness.
ReplyDeleteThis might fit with an AIVR from an inferior lead MI. There seems to be some progression of inferior lead ST elevation, but it's tough to say. However, there is little reciprocal change in the lateral leads.
I don't think those are pacer spikes V4 and V5, just artifact.
A supraventricular tachycardia with a pre-excitation rhythm is unlikely as the rate is too slow and the baseline in II and V1 seem to be without a.fibrillatory or a.flutter waves. But then again, something crazy is going on with the baseline in V1 and II.
The fact that the rate is too slow for a SVT does not r/o a pre-excitation syndrome, but that's an unlikely diagnosis, because it doesn't fit the overall picture.
ReplyDeleteI think nothing "crazy" is going on. The fact that there are no "left ventricular" complexes, that the QRS is that grossely broad and that the rhythm is absolutely regular, points towards a pacemaker rhythm. Also, I hardly believe the spikes seen in V4-V5 are artifacts, as they are too constant and well placed. I think this fellow might be in need of a battery change. If his pacemaker is malfunctioning this might cause instants of rather serious bradycardia and c/p, which might logically be relieved by exertion. In short, I'd take him to a hospital where they can keep him monitored until his pacemaker's checked.
Hyper K
ReplyDeleteIt's definitely a paced rhythm. However, this doesn't diminish the patients complaints of chest pain and palpitations which need investigation, immediately. Because the morphology of a paced complex (i.e. one that originated in the R ventricle and gives a QS wave with large T's) can both mimic or mask any underlying ischemic/infarct presentation. History and enzymes/troponin would be the more reliable indication of an ACS. This ECG only really shows a constant paced rhythm. The tiny spikes are not artifact.
ReplyDeleteI don't think this is ACS. The clinical picture doesn't fit - no pallor, no diaphoresis (admittedly, these symptoms are not mandatory, but you have to have SOMETHING in order to treat for ACS!). Most importantly, patient's pain improves on exertion, right? This points to the source of the pain being either musculo-skeletal or neurologic, or else a "demand ischemia" due to intermittent bradycardia with or without underlying IHD.
ReplyDeleteHowever, I agree that *in principle* such an ECG cannot be said to r/o ACS and that a detailed history and monitoring must be obtained, and also cardiac markers.
By the way, the patient could suffer from a host of pathologies, it's just that we wouldn't know about them from this ECG.
Its apear to be an EAM envolving A-V node with ventricular ectopic foci.Whi thats regular rate? Because that just under A-V node foci...
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