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 "...
Source: Dr. Smith's ECG Blog - December 24, 2023 Category: Cardiology Authors: Pendell Source Type: blogs

A 50-something with Regular Wide Complex Tachycardia: What to do if electrical cardioversion does not work?
Case submitted by anonymous. Written by Smith.  Ken ' s piece at the bottom is excellent.A 50-something presented with sudden onset palpitations 8 hrs prior while sitting at desk at work. He had concurrent sharp substernal chest pain that resolved, but palpitations continued.Over past 3 months, he has had similar intermittent episodes of sharp chest pain while running, but none at rest. Past medical history includes coronary stenting 17 years prior. A brief chart review revealed his most recent echo in 2018, with LV EF 67%, “very small” inferior wall motion abnormality.Initial ED ECG:What do you think?This wa...
Source: Dr. Smith's ECG Blog - September 20, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs

A 50-something with Regular Wide Complex Tachycardiaa: What to do if electrical cardioversion does not work?
Case submitted by anonymous. Written by Smith.  Ken ' s piece at the bottom is excellent.A 50-something presented with sudden onset palpitations 8 hrs prior while sitting at desk at work. He had concurrent sharp substernal chest pain that resolved, but palpitations continued.Over past 3 months, he has had similar intermittent episodes of sharp chest pain while running, but none at rest. Past medical history includes coronary stenting 17 years prior. A brief chart review revealed his most recent echo in 2018, with LV EF 67%, “very small” inferior wall motion abnormality.Initial ED ECG:What do you think?This wa...
Source: Dr. Smith's ECG Blog - September 20, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs

Calcium-Channel Blockers For High Blood Pressure: Types, Side Effects, Drug Interactions
Conclusion In a nutshell, calcium-channel blockers are a valuable tool in the medical arsenal for treating a range of cardiovascular conditions. By inhibiting calcium’s entry into the heart and blood vessel cells, these drugs induce blood vessel dilation and relaxation, reducing blood pressure. Their unique properties and effectiveness make them especially suitable for groups like older adults and people of African descent, and those with conditions like angina, certain arrhythmias, and Raynaud’s disease. Even with the possibility of side effects and drug interactions, calcium-channel blockers are g...
Source: The EMT Spot - July 24, 2023 Category: Emergency Medicine Authors: Michael Rotman, MD, FRCPC, PhD Tags: Blood Pressure Source Type: blogs

20-something with huge verapamil overdose and cardiogenic shock
A 20-something presented after a huge verapamil overdose in cardiogenic shock.  He had been seen at an outside institution and been given 6 g calcium gluconate, KCl, and a norepinephrine drip.The initial K was 3.0 mEq/L and ionized calcium was 5.5 mg/dL (sorry, Europeans, for the weird units)Here was the initial ED ECG:There is a junctional rhythm with retrograde P-waves (see the dip in the T-wave in lead II across the bottom; you can follow that up to all the other leads and see the retrograde P wave).  There is also Left Bundle Branch Block (LBBB). There is huge proportionally excessively discord...
Source: Dr. Smith's ECG Blog - May 26, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs

A woman in her 60s with large T-waves. Are they hyperacute, hyperkalemic, or something else?
 Case written by Brandon Friedman M.D., edits by MeyersA woman in her 60s with a history of chronic atrial fibrillation on Eliquis, ESRD on hemodialysis, type-II diabetes mellitus, prior CVA, hypertension, and hyperlipidemia presented to the emergency department with multiple complaints after missing dialysis. She described a feeling of general unwellness, diarrhea, right-sided abdominal pain, bilateral leg pain, bilateral leg swelling, and diffuse itching. She missed her last two dialysis appointments, with her last session occurring one week prior to presentation. On initial assessment, she was found to be tachycard...
Source: Dr. Smith's ECG Blog - May 1, 2023 Category: Cardiology Authors: Pendell Source Type: blogs

What is strange about this paroxysmal atrial fibrillation in an otherwise healthy patient? And what happened after giving ibutilide?
Conclusions.The efficacy of transthoracic cardioversion for converting atrial fibrillation to sinus rhythm was enhanced by pretreatment with ibutilide. However, use of this drug should be avoided in patients with very low ejection fractions. (N Engl J Med 1999;340:1849-54.) Smith comments from the full text: They included patients who had had a fib for less than 48 hours  They excluded patients with a fib for longer than 48 hours unless they proved, by TE echo, to not have an atrial thrombus OR unless they anti-coagulated them for 3 weeks first *Therefore, our patients who have been in afib< 48 hours, or who h...
Source: Dr. Smith's ECG Blog - March 13, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs

One family ’s disastrous experience with a growth-driven long-term care company
by “E-PATIENT” DAVE DEBRONKART Continuing THCB’s occasional series on actual experiences with the health care system. This is the first in a short series about a patient and family experience from one of America’s leading ePatients. I’ve been blogging recently about what happens in American healthcare when predatory investor-driven companies start moving into care industries because the money’s good and enforcement is lax. The first two posts were about recent articles in The New Yorker on companies that are more interested in sales and growth than caring. I now have permission ...
Source: The Health Care Blog - January 10, 2023 Category: Consumer Health News Authors: matthew holt Tags: The Business of Health Care ePatient Dave Patient Experience Respite care Source Type: blogs

Which chemotherapeutic agent is well known to cause coronary vasospasm?
5-fluorouracil is well known to cause coronary vasospasm. 5-fluorouracil and its orally active prodrug capecitabine are fluoropyrimidines, belonging to the class of antimetabolites used for treatment of malignancies of breast, head and neck tumours and gastrointestinal tumours. Mechanisms for coronary vasospasm Endothelial cell damage with cytolysis and denudation Increased endothelin-1 bioactivity leading to vasoconstriction When high dose infusions are given, coronary vasospasm with angina, arrhythmia or even sudden death can occur in up to 5% of patients. Vascular toxicity occurs generally within 72 hours of the...
Source: Cardiophile MD - November 13, 2022 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs

Back to basics: what is this rhythm? What are your options for treating this patient?
Written by Bobby Nicholson MD, with edits by Meyers, Smith, GrauerA woman in her early 40s presented to the emergency department for evaluation of palpitations. She reported that she has been experiencing this since she was diagnosed with COVID a little over 1 week ago. She reported a prior history of SVT and has previously performed vagal maneuvers at home with symptom resolution. She reports that she is now unable to vagal out of her palpitations and is having shortness of breath and dull chest pain. Her initial EKG is below.We see a regular tachycardia with a narrow QRS complex and no evidence of OMI or subend...
Source: Dr. Smith's ECG Blog - October 25, 2022 Category: Cardiology Authors: Pendell Source Type: blogs

A woman in her 60s with palpitations, chest discomfort, and multiple misdiagnoses by both EM and Cardiology!!
 Written by Pendell MeyersA woman in her 60s was shopping when she suddenly experienced palpitations and chest " discomfort. " She denied outright chest pain or dyspnea. She walked across to the street to my Emergency Department. She had no known prior history of dysrhythmias or heart disease, but had known hypertension, breast cancer, diabetes, and obesity. She has had episodes of palpitations in the past, followed by holter monitor workups which did not reveal any cause of palpitations. However, her symptoms today feel worse than prior episodes, and she has never felt the " chest discomfort " with prior palpitations...
Source: Dr. Smith's ECG Blog - September 21, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

Narrow Complex Tachycardia at a Rate of 220
40-something yo who is on flecainide and diltiazem had suddenonset chest pain, palpitations, shortness of breath and diaphoresis:Rate is 220.  What do you think?It is fast, narrow, and regular, without P-waves.  So it isnot atrial fib andnot VT.  It is a regular narrow complex tachycardia.  There is a lot of ST depression -- this is ischemia caused by the very fast rate and is an indication for emergent electrical cardioversion.What is the DDx?  ----PSVT (which includes AVNRT and orthodromic AV reciprocating tachycardia) [AVRT uses an accessory pathway, a " bypass tract " a...
Source: Dr. Smith's ECG Blog - September 17, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

A woman in her 40s with palpitations and chest pressure of unusual etiology
Submitted and written by Magnus Nossen MD from Norway, with some minor edits by Meyers and SmithA female in her 40s with no known cardiac disease presented to the ED with palpitations and presyncopal episodes recurring over several years, usually lasting 1-5 minutes, sometimes associated with chest discomfort, and increasing in frequency over the past few months. Previously she had an echo and 5 days ambulatory ECG performed at a private clinic, both normal. The suspected arrhythmia had evaded capture. She then purchased a smart watch with the possibility for ECG recording. She presented to the emergency room with pri...
Source: Dr. Smith's ECG Blog - April 25, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

Fascinating case of dynamic shark fin morphology - what is going on?
 Case submitted by Magnus Nossen MD from Norway, written by Pendell MeyersA man in his 50s with no pertinent medical history suffered a witnessed cardiac arrest. EMS found the patient in VFib and performed ACLS for 26 minutes then obtained ROSC. 12 minutes later, the patient went back into VFib arrest and underwent another 15 minutes of resuscitation followed by successful defibrillation and sustained ROSC. In total, he received approximately 40 minutes of CPR and 7 defibrillation attempts. Here is his first ECG recorded after stable ROSC:Originally recorded in 50 mm/s (the standard in Norway), here converted to ...
Source: Dr. Smith's ECG Blog - October 26, 2020 Category: Cardiology Authors: Pendell Source Type: blogs

Antiarrhythmic drug classification
The popular Vaughan Williams classification was published in 1975 [1]. It is still being used by most of us. The Sicilian Gambit published in 1991 [2] has not been so popular because of its complexity. Vaughan Williams classification is approximately as follows:  Class I: Sodium channel blockers ◦a: Moderate Na channel block. e.g. Quinidine, Disopyramide ◦b: Weak Na channel block. e.g. Lignocaine, Mexiletine ◦c: Marked Na channel block. e.g. Flecainide, Propafenone  Class II: Beta blockers  Class III: Potassium channel blockers: Amiodarone, Sotalol, Ibutilide  Class IV: Calcium channel blockers In 2018, an exten...
Source: Cardiophile MD - October 13, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: ECG / Electrophysiology Source Type: blogs