Bradycardia, SOB, in a Dialysis Patient

A dialysis patient presented with dyspnea and a heart rate of 33.  His medications included amlodipine and carvedilol.  He has a history of hypertension and DM.  His BP was 150/45 (bradycardia leads to long run-off time after each systolic beat, leading to low diastolic pressure).  He appeared comfortable, in no distress.QRS duration is normal at 97 ms.  What is the diagnosis until proven otherwise?This ECG shows a junctional bradycardia (either sinus arrest with junctional escape, or severe sinus bradycardia with junctional escape), with retrograde P-waves (see the negative deflection just after the QRS in lead II, and the positive deflection just after the QRS in V1).  Because this patient has LVH and left atrial enlargement, he normally has a negative P-wave in V1 (see below); with retrograde activation, the atrium depolarizes from inferior to superior, changing its polarity on the ECG to upright. A dialysis patient with bradycardia has hyperkalemia until proven otherwise.  In this case, the K was 7.5 mEq/L.  Notice there are no other signs of hyperK such as peaked T-waves.Here is his ECG from 2 weeks prior, when his K was 6.5 mEq/L:It looks nearly identical, except for the rhythm, which is sinus bradycardiaOf course, this bradycardia could be caused by carvedilol and/or amlodipine, or the combination.  And also by sick sinus syndrome.If the K had not been high, these would have been the likely culprits.Management:Before waiting...

Source: Dr. Smith's ECG Blog - July 13, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs