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She had a single chamber ICD/Pacemaker implanted several years prior due to ventricular tachycardia. Answer : The ECG above shows a regular wide complex tachycardia. Said differently, the ECG shows a rather slow ventricular tachycardia with a 2:1 VA conduction. Cardiac output (CO) was being maintained by the tachycardia.
Shortly after isoprenalin infusion was initiated, there were short runs of ventricular tachycardia. The physiologic reason for this — is thought to be the result of momentarily increased circulation from mechanical contraction arising from the "sandwiched in" QRS complex. She was started on isoprenalin (isoproterenol).
Physiologically — the most commonly observed pattern of AFlutter, known as " Typical " AFlutter — produces 2:1 negative deflections seen in the inferior leads ( as seen in Figure-3 ) — as a result of CCW ( C ounter C lock W ise ) rotation of a fixed reentrant circuit around the tricuspid valve annulus and through the cavo-tricuspid isthmus.
The atrial rate is around 120 beats per minute, which indicates high adrenergic state and physiologic distress! This is sinus tachycardia (rhythm) with complete heart block (AV node function) with ventricular escape rate just below 30. Never forget that sinus tachycardia is the scariest arrhythmia.
(Ken Grauer points out that this 5th beat appears to be due to an early atrial beat and that these early beats continue for a few beats, suggesting a short run of atrial tachycardia.) The 6th beat (the one with the 5th visible pacer spike) has a pacing spike in the midst of the QRS. The pacemaker is not always "right".
Tachycardia (or nearly) 2. Tachycardia, = 1.8. Finally , they found these independent predictors of PE: Note that tachycardia only has an Odds ratio of 1.8. Tachycardia is unusual in ACS unless there is cardiogenic shock or a second simultaneous pathology. Some providers were worried about ACS because of this ECG.
One looks for sinus tachycardia and diffuse low voltage but many conditions produce these nonspecific findings. Physiologically the ECG finding of electrical alternans correlates with the presence of a swinging heart within the pericardial sac on Echo.
That said — as we have shown in multiple posts on Dr. Smith’s ECG Blog ( See My Comments in the October 5, 2020 and the October 3, 2018 posts) — there will often be clues to OMI on a paced ECG — IF you know how to look for them. Did YOU Notice that the underlying rhythm in Figure-1 appears to be atrial tachycardia?
ie, See My Comment at the bottom of the page in the March 6, 2020 post in Dr. Smith's ECG Blog — in which I illustrate near the very end of my March 6, 2020 Comment the initiation of "fast-slow" form of AVNRT by what we see here in Panel B ). Dual AV physiology is necessary for AVNRT and reciprocal or "echo" beats.
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