Arrhythmia? Ischemia? Both? Electricity, drugs, lytics, cath lab? You decide.

Written by Pendell Meyers with edits by Steve SmithA male in his 60s presented with off and on shortness of breath and chest pressure over the past few days. He was hypertensive and tachycardic, with mildly increased work of breathing. Here is his initial ECG:What do you think? What will you do for this patient? How many problems does he have?When the team saw this ECG, we obviously noticed the large STE in the inferior leads, with STD in V1-V5, I, and aVL, and STE in V6. However we also noticed that the rhythm is rapid, regular, and narrow, with no P-waves, at a rate of approximately 200 bpm, and therefore not sinus rhythm in this patient in his 60s. The axiom of " type 1 (ACS, plaque rupture) STEMIs are not tachycardic unless they are in cardiogenic shock " is not applicable outside of sinus rhythm. The rhythm differential for narrow, regular, and tachycardic is sinus rhythm, SVT (encompassing AVNRT, AVRT, atrial tach, etc), and atrial flutter (another supraventricular rhythm which is usually considered separately from SVTs). Therefore this patient is either in some form of SVT or atrial flutter. Atrial flutter, when regular, must be conducting at 1:1, 2:1, 3:1, etc. If 1:1, a regular ventricular rate of 200 as the result of atrial flutter would require a flutter rate of 200, and that is too slow for flutter (unless the patient is taking a type I antidysrhythmic such as flecainide, which slows atrial conduction and flutter rate). Atrial flutter in the ab...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs