A fascinating electrophysiology case. What is this wide complex tachycardia, and how best to manage it?

The patient is female in her 80s with a medical hx of previous MI with PCI and stent placement. She also has a hx of paroxysmal atrial fibrillation and is on oral anticoagulant treatment. She had a single chamber ICD/Pacemaker implanted several years prior due to ventricular tachycardia. The last echocardiography 12 months ago showed HFmrEF.She presented to the emergency department after a couple of days of chest discomfort. The ECG below was recorded. What is your assessment? How would you manage this patient?The ECG was interpreted as showing atrial flutter with 2:1 conduction. The patient was deemed stable and the decision was made to put the patient on IV amiodarone. Do you agree with this strategy? Would you treat the patient in any other way? What about the ST segments, do they worry you? Are you confident there is no ischemia? How can you better assess the ST segments?Answer: The ECG above shows a regular wide complex tachycardia. The heart rate is about 130 bpm. The heart rate could be compatible with that of a 2:1 conducted atrial flutter. Also, lead I could give the initial impression of showing flutter waves. Looking more closely at the tracing however, it becomes apparent thatatrial activityis not consistent with atrial flutter. Clear atrial activity is visualized in the inferior leads whereinverted P waves are seen buried in every other ST-segment. P waves are of negative polarity in the inferior leads, meaning they are conducted retrogradely from the A...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs