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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.
She also has a hx of paroxysmal atrialfibrillation and is on oral anticoagulant treatment. 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.
edits by Meyers A woman in her 60s with a history of chronic atrialfibrillation on Eliquis, ESRD on hemodialysis, type-II diabetes mellitus, prior CVA, hypertension, and hyperlipidemia presented to the emergency department with multiple complaints after missing dialysis. They are flutter waves, and the rhythm is 2:1 atrialflutter.
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.
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.
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. Rhythm abnormalities (atrialfibrillation or flutter, supraventricular tachycardia, multifocal atrial tachycardia, frequent or repetitive premature supraventricular or ventricular complexes, sustained or non-sustained ventricular tachycardia, paced rhythms), 2.
No evidence for ischemia jumps out. Cardioversion is most beneficial for reentrant arrhythmias ( e.g. VT, atrialflutter, AVNRT, atrialfibrillation) because it terminates the reentry circuit. He said he had had three episodes of chest pain that day while urinating. ECG 1 What do you think?
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