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This narrows our differential for the rhythm down to sinus tachycardia, paroxysmal supraventricular tachycardia (PSVT, or SVT), and atrialflutter. The patient’s history is notable for paroxysmal atrial fibrillation, which raises clinical suspicion for atrialflutter, since these two entities frequently coexist on a spectrum.
The ECG was interpreted as showing atrialflutter with 2:1 conduction. Are you confident there is no ischemia? The heart rate could be compatible with that of a 2:1 conducted atrialflutter. Also, lead I could give the initial impression of showing flutter waves. Do you agree with this strategy?
Here I put arrows: Arrows shows slow atrialflutter waves. Arrhythmia? Today’s case recalled that scenario for me, in that it features recognition of an arrhythmia that fooled ED staff into thinking the ECG was showing an acute infarction. These mimic ST Elevation. But there is no STE. Would you give lytics?
Re-entrant tachycardias (atrialflutter, PSVT, AVRT, VT) have constant regular heart rates, whereas sinus tachycardia will usually gradually change rate with differing conditions (for instance, after infusion of fluid and BP increase, sinus tach rate might decrease from 130 to 125, for instance). So there is a re-entrant rhythm.
A series of cardiac arrhythmias were seen during the course of her resuscitation — including the interesting arrhythmia shown in the long lead II of Figure-1. At about this point in the process — I like to take a closer LOOK at the 12-lead tracing, to ensure there is no acute ischemia or infarction that might need immediate attention.
We see a regular tachycardia with a narrow QRS complex and no evidence of OMI or subendocardial ischemia. The differential of a regular narrow QRS tachycardia is sinus tachycardia, SVT, and atrialflutter with regular conduction. There are no P waves preceding the QRS complexes, and no clear flutter waves.
The Differential Diagnosis is: SVT with aberrancy(#) [AVNRT vs. WPW (also called AVRT*)] Atrialflutter with 1:1 conduction, with aberrancy VT coming from the anterior fascicle ( fascicular VT )@ *AVRT = AV Reciprocating Tachycardia (Tachycardic loop that uses both the AV node and an accessory pathway.
The rhythm differential for narrow, regular, and tachycardic is sinus rhythm, SVT (encompassing AVNRT, AVRT, atrial tach, etc), and atrialflutter (another supraventricular rhythm which is usually considered separately from SVTs). Therefore this patient is either in some form of SVT or atrialflutter.
Atrialflutter with 2:1 conduction. The atrialflutter rate is approximately 200 bpm, with 2:1 AV conduction resulting in ventricular rate almost exactly 100 bpm. Further history revealed she had new onset atrialflutter soon after her aortic surgery, and was put on flecainide approximately 1 month ago.
There is a large peaked P-wave in lead II (right atrial enlargement) There is left axis deviation consistent with left anterior fascicular block. There is no evidence of infarction or ischemia. There is atrial activity before every QRS, but that activity has negative polarity, so it is not sinus rhythm.
Evidence of acute ischemia (may be subtle) vii. Finally, much of this correlates well with The new Canadian Syncope Arrhythmia Risk Score , just published in 2016, results of which are given below in the Annotated Bibliography. The most recent and probably best study is this: Canadian Syncope Arrhythmia Risk Score. Left BBB vi.
No evidence for ischemia jumps out. But ectopic atrial tachycardia is most commonly an automatic arrhythmia. Cardioversion is most beneficial for reentrant arrhythmias ( e.g. VT, atrialflutter, AVNRT, atrial fibrillation) because it terminates the reentry circuit. ECG 1 What do you think?
The possibility of an ischemic cause of the ventricular arrhythmia has to be considered! That said there were no clinical symptoms or ECG findings suggestive of ongoing ischemia. A workup was undertaken in search of a cause of the patient's ventricular arrhythmia. The idiopathic VTs are an interesting group of arrhythmias!
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