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
Young Man with a Heart Rate of 257. What is it and how to manage?
A 30-something was in the ED for some minor trauma when he was noted to have a fast heart rate. He acknowledged that he had palpitations. but only when asked. He had a history heavy alcohol use. Blood pressure was normal (109/83).Here is his 12-lead:There is a wide complex tachycardia with a rate of 257, with RBBB and LPFB (right axis deviation) morphology.The Differential Diagnosis is: SVT with aberrancy(#) [AVNRT vs. WPW (also called AVRT*)] Atrial flutter with 1:1 conduction, with aberrancy VT coming from the anterior fascicle (fascicular...
Source: Dr. Smith's ECG Blog - September 6, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs
A Young Woman with Regular Narrow Complex Tachy at both 160 and 240
This article studied their effect in pediatrics:https://www.ahajournals.org/doi/full/10.1161/CIRCEP.109.901629===================================MY Comment by KEN GRAUER, MD (5/30/2020):===================================Fascinating case presented by Dr. Smith (!) — about this young woman who presented with palpitations and sequential reentry SVT rhythms — initially at a ventricular rate of ~160/minute — and then following administration of 6mg IV adenosine, another reentry SVT at a much faster rate of ~240/minute. HOW could this happen?For clarity — ...
Source: Dr. Smith's ECG Blog - May 30, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs
New Onset Heart Failure and Frequent Prolonged SVT. What is it? Management?
This middle-aged man with no cardiac history but with significant history of methamphetamin and alcohol use presented with chest pain and SOB, worsening over days, with orthopnea.BP:143/99, Pulse 109, Temp 37.2 °C (99 °F), Resp (!) 32, SpO2 95%On exam, he was tachypneic and had bibasilar crackles.Here was his ED ECG:There is sinus tachycardia (rate about 114) with nonspecific ST-T abnormalities.There is a large peaked P-wave in lead II (right atrial enlargement)There is left axis deviation consistent with left anterior fascicular block.There are nonspecific ST-T abnormalities.There is no evidence of infarction or ischemi...
Source: Dr. Smith's ECG Blog - March 5, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs
A man in his early sixties with palpitations
Case submitted and written by James Tavornwattana, edits by Pendell Meyers and Steve SmithA male in his 60s with diabetes presented to the ED with one hour of palpitations associated with a 30 min episode of throat burning sensation when he woke up this morning. He denied chest pain, shortness of breath, or lightheadedness.Initial ECG (0 hr):What do you think?Interpretation:Atrial fibrillation with rapid ventricular responseST depression that is maximal in V2-V4, also with lesser STD in V5, I, aVL, II and aVF. With multi-lead STD, there is of course STE in aVR.This pattern and location of STD (maxi...
Source: Dr. Smith's ECG Blog - January 11, 2020 Category: Cardiology Authors: Pendell Source Type: blogs
Chemotherapeutic agent causing coronary vasospasm – Cardiology MCQ – Answer
Chemotherapeutic agent causing coronary vasospasm – Cardiology MCQ – Answer
Chemotherapeutic agent well known to cause coronary vasospasm:Correct answer: c) 5-fluorouracil
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, arrh...
Source: Cardiophile MD - February 22, 2019 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology MCQ DM / DNB Cardiology Entrance Source Type: blogs
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 ...
Source: Dr. Smith's ECG Blog - November 26, 2018 Category: Cardiology Authors: Pendell Source Type: blogs
Live the Wheat Belly lifestyle, get off prescription medications
Take a look at the list of medications people have been able to stop by following the Wheat Belly lifestyle.
These represent medications prescribed by doctors to, in effect, “treat” the consequences of consuming wheat and grains. They prescribe drugs to treat inflammation, swelling, skin rashes, gastrointestinal irritation, high blood sugars, airway allergy, joint pain, high blood pressure, leg edema and other abnormal effects caused by wheat and grains.
The list includes anti-inflammatory and pain medication, acid reflux drugs, injectable and oral drugs for diabetes, numerous anti-hypertensive agents, asthma i...
Source: Wheat Belly Blog - October 27, 2018 Category: Cardiology Authors: Dr. Davis Tags: News & Updates autoimmune blood sugar bowel flora cholesterol Gliadin gluten-free grain-free grains Inflammation undoctored Weight Loss wheat belly Source Type: blogs
Idiopathic Ventricular Tachycardias for the EM Physician
Written by Pendell Meyers, reviewed by Steve Smith and Scott Weingart“Idiopathic ventricular tachycardias” refer to a group of tachydysrhythmias originating below the AV node and bundle of His but differing in etiology, prognosis, and treatment compared to classic ventricular tachycardia (VT). The name “idiopathic” is becoming more and more inappropriate, as various specific subgroups and specific etiologies are being discovered, including right ventricular outflow tract VT, fascicular VT, and bundle branch reentrant VT. To understand these entities one must first understand the differences between classic VT and i...
Source: Dr. Smith's ECG Blog - September 14, 2018 Category: Cardiology Authors: Pendell Source Type: blogs
IV bolus diltiazem followed by immediate release oral for patients presenting with rapid atrial fibrillation
(Source: Notes from Dr. RW)
Source: Notes from Dr. RW - May 6, 2018 Category: Internal Medicine Tags: cardiovascular pharmacology Source Type: blogs
ST-Elevation in aVR with diffuse ST-Depression: An ECG pattern that you must know and understand!
This case comes from Sam Ghali (@EM_RESUS). A 60-year-old man calls 911 after experiencing sudden onset chest pain, palpitations, and shortness of breath. Here are his vital signs:HR: 130-160, BP: 140/75, RR:22, Temp: 98.5 F, SaO2: 98%This is his 12-Lead ECG:He is in atrial fibrillation with a rapid ventricular response at a rate of around 140 bpm. There are several abberantly conducted beats. There is ST-Elevation in aVR of several millimeters and diffuse ST-Depression with the maximal depression vector towards Lead II in the limb leads and towards V5 in the precordial leads.ECG reading is all ab...
Source: Dr. Smith's ECG Blog - February 28, 2018 Category: Cardiology Authors: Steve Smith Source Type: blogs
Altered Mental Status, Bradycardia
911 was called for an elderly woman who fell and was confused. Medics found her unresponsive, with " convulsive " movements. They could not find a pulse. They performed CPR, gave epinephrine, and intubated the patient and regained a pulse, at which time she became responsive and had this prehospital ECG:On arrival, heart rate was 87 and she was hypotensive at 52/21, with a palpable pulse and cardiac function present on echo. She was intubated (by medics), but awake and alert and nodding to questions, shaking her head " no " to chest pain, headache, or SOB. Repeat pulse was slow and irregular.&...
Source: Dr. Smith's ECG Blog - February 19, 2018 Category: Cardiology Authors: Steve Smith Source Type: blogs
Inferolateral ST elevation, vomiting, and elevated troponin
Another post written by Pendell Meyers, with edits from Dr. Smith:A male in his late 40s presented with nausea, vomiting, and epigastric abdominal pain of several hours duration. An ECG was recorded from triage:What is your interpretation?The ventricular rate is 160 bpm and regular with narrow complex. Rhythm differential is therefore sinus tachycardia, SVT (AVRT, AVNRT, etc), or atrial flutter. There is clear ST elevation present in V4-V6, as well as II, III, and aVF. No clear reciprocal changes in aVL, however with this distribution you could consider a very rare case in which high lateral STE cancels out reciprocal STD....
Source: Dr. Smith's ECG Blog - October 6, 2017 Category: Cardiology Authors: Pendell Source Type: blogs
An irregularly irregular wide complex tachycardia
This was written by Pendell Meyers, a G2 of the Stony Brook residency who has a keen interest in ECGs and who is going to start to help edit this blog. It was edited by me (Smith).Below is a common and important ECG that somehow hasn ' t made it onto this blog yet!CaseA middle aged man presented with acute shortness of breath. He was hemodynamically stable but in mild respiratory distress, with diffuse B-lines and requiring BIPAP.Here is his initial ECG:What is your interpretation? What is the rhythm? Are there signs of acute coronary occlusion?This shows an irregularly irregular wide complex tachycardia at a rat...
Source: Dr. Smith's ECG Blog - August 26, 2017 Category: Cardiology Authors: Pendell Source Type: blogs
What happens when you give adenosine to a patient with this rhythm?
A 40-something presented with palpitations and had a regular pulse at 170.Here is his 12-lead ECG:The computer reads supraventricular tachycardia.What is it?It is atrial flutter with 2:1 conduction. It is not PSVT and not sinus.There are clear flutter waves in lead II across the bottom. In V1, there are upright waves that appear to be P-waves but are not: they are atrial waves and it is typical for atrial flutter waves to be upright in V1, whereas sinus P-waves are biphasic in V1.The flutter rate is relatively fast at 334, such that the ventricular rate is 167 (one half the atrial rate).As easy as it may seem to ...
Source: Dr. Smith's ECG Blog - August 23, 2017 Category: Cardiology Authors: Steve Smith Source Type: blogs
