Patient with Paced Rhythm in Severe Cardiomyopathy Presents with SOB due to Acute Decompensated Heart Failure

This is a middle-aged male with h/o with a history ofheart failure with severely reducedejection fraction due to dilated ischemic cardiomyopathy (EF 5-10%), probably with some component of non-ischemic cardiomyopathy, with h/o CABG, who is status post ICD placement (and previous appropriate shocks for VT) and biventricular pacer ( " cardiac resynchronization therapy " ), who is on amiodarone for VT suppression, and has h/o LV thrombus and is on chronicanticoagulation with warfarin.He presented forparoxysmal nocturnal dyspnea that didn ' t resolve with use of his home prn diuretics.  He was hypoxic and required oxygen in the ED.He had no chest pain.Prior coronary angiography/revascularization: LAD 40% proximal, 80% mid and 90% distal stenosis; circumflex 70% proximal circumflex; ramus 100% occluded; RCA 90% occluded.Prior echocardiographic study:(1/9/2017) LVEF is 10%, regional WMAs: distal septum anterior and apex, inferior and anterolateral; left ventricular enlargement and concentric hypertrophy; Severe decreased right ventricular systolic performance; no significant change compared to previous.Upon arrival to the ED, he was hypoxic, but readily responded to oxygen.  An ECG was recorded:Biventricular Paced Rhythm, rate 60QRS = 265 ms, QT = 587, QTc = 610(See two spikes approximately 40 ms apart, with large R-wave in V1 confirming LV pacing in addition to RV -- LV pacing results in RBBB configuration with large R-wave in V1)There is mu...

Source: Dr. Smith's ECG Blog - June 9, 2018 Category: Cardiology Authors: Steve Smith Source Type: blogs