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IMPRESSION: The finding of sinus bradycardia with 1st-degree AV block + marked sinus arrhythmia + the change in PR interval from beat #5-to-beat #6 — suggests a form of vagotonic block ( See My Comment in the October 9, 2020 post in Dr. Initial high sensitivity troponin I returned at 6ng/L (normal 0.20
Discontinue all negative chronotropic agents, since the risk of torsade is much higher with bradycardia or pauses. Finally, do a coronaryangiogram Possible alternative to pacing is to give a beta-1 agonist to increase heart rate. The plan: 1. See this post: How a pause can cause cardiac arrest 2. Place temporary pacemaker 3.
Soon afterward, the patient’s symptoms return along with lightheadedness, bradycardia, and hypotension. The patient has also developed sinus bradycardia, which may result from right coronary artery ischemia to the SA node. The Queen of Hearts agrees: Around this time his initial high sensitivity troponin I resulted at 231 ng/L.
Perhaps a more balanced approach is that this could equally have been a case where the patient arrives to the ED, is worked up for “non-specific” ST changes and, in the process of such a disposition, is allowed to infarct transmurally while awaiting next-day coronaryangiogram where reduced LV systolic function is encountered.
Three months prior to this presentation, he received a pacemaker for severe bradycardia and syncope due to sinus node dysfunction. The ED provider ordered a coronary CT scan to assess the patient for CAD. The patient was taken emergently to the cath lab for a pericardiocentesis instead of a coronaryangiogram.
A coronaryangiogram was done that did not show significant coronary artery disease. Had there been recurrent episodes of pause-dependent TdP, temporary ventricular pacing at a higher heart rate would have been indicated to suppress the pauses and in that way decreasing the risk of further episodes of TdP.
His first electrocardiogram ( ECG) is given below: --Sinus bradycardia. Here is the coronaryangiogram: A distal thrombotic right coronary artery (RCA) occlusion ! Blood pressure: 130/80 mmHg, heart rate: 45/min, respiratory rate: 18/min, SaO2: %98, body temperature: normal. No reciprocal ST-segment depression (STD). --QT
There are 2 main options: Overdrive pacing could be considered and in the right clinical situation, this is often effective for reducing ventricular arrhythmias ( especially in the case of preventing pause induced or bradycardia-induced arrhythmias in association with QTc prolongation ). Try a different kind of antiarrhythmic.
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