Wide Complex Tachycardia with Huge ST Elevation. What is going on?
This 70-something woman with no significant past history (no previous ECGs or cardiac history) presented by EMS with fairly acute chest pressure and shortness of breath, with nausea and diaphoresis. " Like an elephant sitting on my chest. " She had no history of atrial fibrillation and was not on any anticoagulants.She stated that she had had a similar episode a couple weeks earlier, lasting 24 hours, with rapid heart beat but without chest pain, that spontaneously resolved. She thought she was having a panic attack. Since then she has had " little spurts " of the same thing lasting 1-2 hours.E...
Source: Dr. Smith's ECG Blog - January 12, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
Important aspects in the management of neurocardiogenic syncope
Neurocardiogenic syncope is the most common cause of syncope. Initial measures in management include lifestyle modifications, increasing the fluid and salt intake and education about physical counterpressure methods. Pharmacological measures may be tried next. Pacemaker implantation has been tried in those with predominantly cardioinhibitory syncope [1].
Physical counterpressure measures are movements like leg crossing and hand gripping which may prevent loss of consciousness in those who feel the presyncopal symptoms. These measures increase the systemic vascular resistance and blood pressure to counter the vasodepressiv...
Source: Cardiophile MD - November 20, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: General Cardiology Source Type: blogs
A woman in her 60s with syncope and vomiting. Does she need a pacemaker?
Written by Pendell Meyers with some edits by Steve SmithA woman in her 60s on chemotherapy presented to the Emergency Department for a syncopal episode just prior to arrival. She was walking to the bathroom when she suddenly felt nauseous and passed out. EMS was called by the patient ' s daughter, and en route to the ED she vomited twice. On arrival to the ED, she adamantly denies chest pain but says she ' s " just still not feeling well. " She had no prior known cardiac disease.Triage at 0755:The rhythm is most either atrial fibrillation with complete heart block and resulting junctional escape, or atrial flutter wi...
Source: Dr. Smith's ECG Blog - November 19, 2021 Category: Cardiology Authors: Pendell Source Type: blogs
A woman in her 60s with misdiagnosed palpitations, part 2: Case follow up!
Written by Pendell MeyersThis post will be follow up information on the patient from this recent case linked below. Make sure to read that one first, then see what happened to this patient in this post below!A woman in her 60s with palpitations, chest discomfort, and multiple misdiagnoses by both EM and Cardiology!!Here is the ECG:Here is the explanation:We see a regular, narrow, monomorphic tachycardia, for which the full differential would include sinus tachycardia, SVT (an umbrella term including many different rhythms), and atrial flutter. This ECG has a large negative atrial wave just before the QRS complex...
Source: Dr. Smith's ECG Blog - October 4, 2021 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
Syncope in a young man
Written by Pendell MeyersLet ' s say a young person presented with exertional syncope. They are now at baseline, asymptomatic, normal vital signs, and they have this ECG at triage:What do you think?Below are two other variations of this patient ' s resting ECG from different time periods:Answer: Arrhythmogenic Right Ventricular CardiomyopathySee the end of the post for review and details on ARVC and it ' s ECG findings, but suffice to say that this patient has sinus rhythm, small epsilon wave in some of his ECGs, and R waves in V1-V3 with TWI.Here is a close up of V1-V3:Notice the very subtle micro-voltages at the J ...
Source: Dr. Smith's ECG Blog - September 16, 2021 Category: Cardiology Authors: Pendell Source Type: blogs
Paroxysmal Atrial Fibrillation with RVR, hypotension, volume depletion, good EF, AND pulmonary edema. Strange. Why? What to do?
A 30-something woman presented with a few days of feeling ill. She had a history of paroxysmal atrial fibrillation, bio-prosthetic mitral valve, and tricuspid valvuloplasty, and was on Coumadin.Records showed she is usually in sinus rhythm and has normal LV function.She presented hypotensive (systolic pressure 80), with diffuse B lines, flat IVC, good LV function, and an irregular, fast heart beat.Here is here ECG:Atrial fib with RVR and some probable ischemic ST depression in V3-V6Here is her POCUS:What do you think? There is asmall LV with good function and alarge left atrium, andmoderately large RV.Ther...
Source: Dr. Smith's ECG Blog - April 4, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs
20-something with anxiety. Pulse is 169. Then 229. Then 169. Then 229. Latent conduction vs. Concealed Conduction. 3 Pathways.
A young woman in her third trimester of pregnancy had complained of panic attacks on multiple occasions. She presented to the ED this time, instead of to a clinic, for the same complaint and her pulse was palpated at " very fast " .Side note: Many panic attacks are diagnosed as SVT by 3 year followup. In other words, the patient was wrongly diagnosed and treated for psychiatric disease for up to 3 years.Lessmeier TJ, Gamperling D, Johnson-Liddon V, et al. Unrecognized paroxysmal supraventricular tachycardia. Potential for misdiagnosis as panic disorder. Arch Intern Med. 1997;157(5):537-543. More I...
Source: Dr. Smith's ECG Blog - March 25, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs
The Art of Prescribing (Or Not)
By HANS DUVEFELT
I have learned a few things about prescribing medications during my 42 years as a physician. Some are old lessons, and some are more recent. I thought I’d share some random examples.
First: I don’t like to have to use medications, but when they seem necessary, I choose, present and prescribe them with great care.
CHOOSING MEDICATIONS
Medications are like people. They have personalities. With so many choices for any given diagnosis or symptom, I consider their mechanism of action, possible beneficial additional effects and their risk of unwanted side effects when selecting which one to presc...
Source: The Health Care Blog - February 1, 2021 Category: Consumer Health News Authors: Christina Liu Tags: Medical Practice Patients Physicians Primary Care Hans Duvefelt Source Type: blogs
Electrical storm – Management
Electrical storm – Management
Electrical storm: Recurrent unstable ventricular tachycardia (VT)/ventricular fibrillation (VF) requiring more than three direct current (DC) shocks per day.
Beta blocker is the single most effective therapy for recurrent VT unless the person is in shock. A combination of intravenous amiodarone with oral propranolol has been found to be superior to intravenous amiodarone with oral metoprolol [1].
Stellate ganglion block / ablation is being increasingly used as a modality for treatment of drug refractory ventricular tachycardia. Temporary blockage of stellate ganglion can be obtained by...
Source: Cardiophile MD - December 18, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: ECG / Electrophysiology Ablation of stellate ganglion Stellate ganglion block Temporary blockage of stellate ganglion 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
Cardiac arrest with anterior-inferior STEMI: Guess the value of the initial ED high sensitivity Abbott troponin I
A ~40 year old woman started having chest discomfort. She called 911 after an uncertain amount of time. EMS arrived and recorded thisprehospital ECG:Obvious Anterior and Inferior STEMI, consistent with LAD occlusionAfter recording this ECG, the patient went intoventricular fibrillation.She was rapidly defibrillated.The cath lab was activated by the paramedics.She arrived complaining of chest pain, with a BP of 110/70.An ED ECG was recorded:It looks worse stillAside: Should the patient receive antidysrhythmics to prevent recurrent VT/VF? See discussion below on both beta blockers and other anti-dysrhythmic...
Source: Dr. Smith's ECG Blog - September 18, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs
A 31 year old with Diabetes and HTN complains of bilateral arm tingling and headache
This ECG was texted to me with the message " A 31 year old with Diabetes and HTN complains of bilateral arm tingling and headache. "There is high lateral ST Elevation and inferior reciprocal ST depression.There is also STE in V2.The computer calls it a STEMI.What do you think?STE in I, aVL and V2 is a pattern associated with "Mid-anterolateral OMI, " which is seen with OMI of the first Diagonal. See more of Mid-anterolateral OMII wrote back: " I think this is a false positive due to LVH. PseudoSTEMI. I can ' t tell you exactly why. It just looks like it. ECGs are often like faces to me.&n...
Source: Dr. Smith's ECG Blog - August 29, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs
This middle-aged patient presented with SOB, weakness, and mild pulmonary edema.
She previously had Atrial fibrillation with LBBB.Here is her ED ECG:Does this reveal the etiology of her symptoms?This shows atrial fibrillation. There is a regular, slow response. The fact that the response is regular proves that the atrial fibrillation is NOT conducting. When atrial fib conducts, the ventricular rate must always be irregular.This is atrial fibrillation with complete (3rd degree) AV block.The QRS morphology is RBBB with a vertical axis. This suggests an LV escape rhythm, possibly from the left anterior fascicle.She previously had known LBBB, so she is lucky that her left sided esca...
Source: Dr. Smith's ECG Blog - January 21, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs
Wide-complex tachycardia that didn ’t follow the rules
ConclusionIt is well worth remembering that this was a rare case! In most middle-aged patients with a history of cardiomyopathy, a WCT will usually be VT. Furthermore, while specific criteria (e.g. precordial RS duration, aVR morphology) may not be perfectly sensitive, the are more likely to be helpful than suspecting 1:1 atrial flutter in patients not taking sodium-channel-blocking antiarrhythmics.Comparison of the old and WCT ECGsmight have suggested an SVT or atrial flutter at the time of presentation. However, it would not have been prudent for most clinicians to try e.g. a calcium-channel blocker as the first age...
Source: Dr. Smith's ECG Blog - December 22, 2019 Category: Cardiology Authors: Brooks Walsh Source Type: blogs
