40 years old man with palpitationWhat does the ECG show ?
What are the further investigations ?
Outline the treatment plan.
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13 comments:
1. The ECG shows narrow complex tachycardia with the rate of 150 beats/min, rhythm irregular, normal axis, slurred upstroke to QRS complex(delta waves) best seen in lead III and AVF.
WPW syndrome with supraventricular tachycardia(atrial fibrillation?)
2. Holter ECG monitoring
3.(a)vagal manoeuvres- carotid sinus massage, Valsalva manoeuvre.
(b)Beta-blockers-propranolol, metoprolol.
(c)Flecainide, amiodarone.
-if hemodynamically unstable-cardioversion
1. ECG shows a narrow complex tachycardia at 148 bpm, with normal axis and some delta waves (not sure).
No p waves were present, and rhythm is irregularly irregular.
2. Need to find out the cause of his AF. Differentials includes: Pericarditis, pulmonary embolism, Infections (Infective endocarditis), connective tissue diseases, valvular heart disease, ischemic heart disease, thyrotoxicosis, electrolyte imbalances.
Therefore history and examination, followed by relevant investigations (depending on suspicion) eg. FBE, UEC with CMP, ESR, CRP, Lipids, Blood cultures, Chest x-rays, echocardiograms, Thyroid function test, V/Q scan or CTPA or D-dimer, possibly antibody screens for CTD eg rheumatoid factors, ANA etc.
Perhaps investigate whether does he really have WPW? electrophysiological studies.
3. Management depends on cause, stability of vital signs and patient's desire.
If cause identified, correct underlying causes. Patient is young, rhythm correction might be warranted as long as underlying causes are correctable and no irreversible cardiac pathology eg Ischemic heart disease.
i. Anticoagulate with warfarin 4 weeks, Investigate with TOE for thrombus.
ii. Correct either with DC version or drugs eg amiodarone, sotalol or fleicanide(must rule out any evidence of LV dysfunction).
iii. Maintainance of sinus rhythm with drugs (amiodarone, sotalol, fleicanide). Monitor for side effects
iv. continue anticoagulation for 4 weeks and review to ensure sinus rhythm maintained and atrium is contracting.
Otherwise rate control, with amiodarone, beta-blockers, or calcium channel blockers. and warfarin anticoagulation.
oops, forgot to add the diagnosis
1.AF
2.AF with underlying WPW?
sorry for adding another post.
regards,
Ron
Yes, the ECG shows Atrial fibrillation. Regarding WPW, hmmm..... somehow the PR interval is normal but some of you think there is delta wave.
What I want to stress in this ECG is the management of AF. If the patient is haemodynamically unstable eg low BP of in acute heart failure then the answer is CARDIOVERSION. If patient is haemodynamically stable, then the 3 concepts are (1) Rate control (2) Rhythm control - not in chronic unless symptomatic (3) Anticoagulate. Thanks for the answers given by shuyu and ronald tan. Remember thyroid function test in AF patients !
Thanks for commenting:)the delta waves..maybe I'm seeing things:P
Have a question..Can WPW syndrome cause arrhythmia by itself or does it need to have other underlying causes(thyrotoxicosis, mitral stenosis..etc)??
Yes, it can cause arrhythmia by itself. It normally causes supraventricular tachycardia. Remember that WPW is due to accessory pathway - Bundle of Kent and it would cause reentry circuit.
I was very amazed with this condition since a medical student :)
Do you know what is bundle of James ?
At last i manage to log on this site:)
Bundle of James is an accessory pathway connecting the atria to the bundle of Hiss, bypassing the delay in the AV node. This is seen in Lown-Ganong-Levine syndrome??
Good. How do you differentiate LGL from WPW based on ECG ?
for me, i would say as the bypass tract connects to the bundle of His instead of AV node, so no delta wave as frequently seen in WPW. besides the QRS comples if of narrow complex instead of the wide QRS.
regarding comments made by shuyu, i am quite confused. if she thinks the diagnosis is WPW syndrome with supraventricular tachycardia, why in her treatment chart, she prescribes BB. does she wanna accelerate the bypass or what?
To differentiate LGL and WPW using ECG: LGL have short PR interval with normal or narrow QRS complex,and it is not presented with delta waves.
huicy,i thought beta blockers are suppose to slow the conduction in the accessory pathway??
the drugs which can increase the conduction in the accessory pathway are adenosine,digoxin,verapamil and lignocaine,right?? Please correct me if I'm wrong:)
I do agree with huicy, if the diagnosis is WPW syndrome with supraventricular tachycardia, isn't prescribing beta blocker would suppress the "safety node" (AV node)and subsequently speed up the propagation of impulses down the accessory pathway resulting in a more rapid ventricular rate?
In this context, is Beta Blocker contraindicated? Please impart knowledge in me.
Thank you
1.ECG shows tachycardia, absence p wave and irregularly irregular rhythm, so my diagnosis is atrial fibrillation
2.2-D eco radiography and chest X-ray, TFT, investigation to evaluate and detect CAD and MS
3Heamodynamic instability- urgent cardiovertion
Heamodynamic stable- IV diltiazem, IV beta blockers or IV digoxin
warfarin prophylaxis for all patient with AF who are having heart valve disease
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