A young woman with palpitations. What med is she on? With what medication is she non-compliant? What management?

 Written by Pendell MeyersA woman in her 20s with connective tissue disorder and history of aortic root and valve repair presented with palpitations. Here is her triage ECG: What do you think?Atrial flutter with 2:1 conduction. The atrial flutter rate is approximately 200 bpm, with 2:1 AV conduction resulting in ventricular rate almost exactly 100 bpm. The fact that the atrial flutter rate is 200 bpm (rather than more typical adult rate of ~300 bpm) suggests that the patient must have one or both of the following:1) enlarged atria ( " bigger race track " )2) sodium channel blockade ( " slower race car " )Her medication list was reviewed, and flecainide was found. Further history revealed she had new onset atrial flutter soon after her aortic surgery, and was put on flecainide approximately 1 month ago.What other medicationshould also be on the med list? An AV nodal blocker (to prevent the possibility of 1:1 conduction if the flecainide slows the flutter rate enough to be conducted 1:1).  This could be a beta blocker such as metoprolol, or a calcium channel blocker such as diltiazem.Metoprolol was also on the medication list.  And so was an appropriate anti-coagulant, since atrial flutter, like fibrillation, can result in thromboembolism and stroke.But clinical history suggested she is only taking the flecainide, not the metoprolol.Several minutes later there was a change in the monitor, and she reported increased palpitations:With the contex...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs