An asymptomatic man in his 50s with heart rate in the 160s - what is the diagnosis? How will you manage this?
Written by Pendell MeyersA man in his late 50s with history of CAD with CABG, COPD, smoking, cirrhosis, and other comorbidities presented for an outpatient scheduled stress test which had been ordered for some exertional shortness of breath, palpitations, and presyncopal episodes over the past few months. When he presented to the office for the stress test, his screening vitals before any test or intervention were remarkable only for a heart rate of 160 bpm. He denied any symptoms whatsoever.A 12-lead ECG was performed in the office:What do you think?The ECG shows a wide complex regular monomorphic tachycardia. I mea...
Source: Dr. Smith's ECG Blog - April 2, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
Toothache, incidental Wide Complex Tachycardia
Discussion by our ElectrophysiologistSmith: “I thought that the wide complex tachy (WCT) could be AVRT or VT” EP: " Antidromic AVRT morphology would essentially be the same as “VT” originating from ventricular the insertion site of the accessory pathway. Therefore, traditional criteria for SVT with aberrancy do not apply to antidromic AVRT (except, that negative concordance can never be AVRT!) " Smith: “But then when the patient converted and had PVCs of exactly the same morphology as the WCT, that it must be VT and not AVRT ” EP: " In cases of intermittent pre-excitation, you cou...
Source: Dr. Smith's ECG Blog - November 17, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs
Arrhythmia basics: How often we need to know the mechanism of arrhythmia ?
How many times you have treated cardiac arrhythmia in both emergency & non-emergency situations?
Infinite times.
How many times did you really bother to know the mechanism of a given arrhythmia before ordering medication or shocking?
Hmm,.. let me think. (Except for AVNRT/ AVRT, and few VTs, very rarely I have worried about the mechanism !)
Why is it so? because treatment takes priority and we are able to tame the arrhythmia even without knowing the real mechanism.
The following slide is a gross summary of the cardiac arrhythmia mechanism
Understanding cardiac arrhy...
Source: Dr.S.Venkatesan MD - November 2, 2020 Category: Cardiology Authors: dr s venkatesan Tags: Basic science -Physiology Brugada syndrome cardiac electrophysiology cardiology -Therapeutics Cardiology-Arrhythmias brady dependent vt eads dads early and late after depolarisation enhanced automaticity vs triggerred activity vs reentry 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
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
Difficult calls in cardiology : Be ready for DC cardioversion during pregnancy !
This report from Taiwan reassures there is no adverse effect by measuring umbilical artery flow (Yu-Chi Wang European Journal of Obstetrics & Gynecology and Reproductive Biology 126 (2006) 268–274)While we consider DC shock during pregnancy is safe for the fetus, still, shock pads close to the abdomen, amniotic fluid being a good conductor of electricity at least one mother showed a sustained contraction of the uterus and fetal distress. This was possibly attributable to DC shock Eleanor J. Barnes BJOG 2003 https://doi.org/10.1046/j.1471-0528.2002.02113.
Final message Most cardiac arrhythmias in pregnancy ...
Source: Dr.S.Venkatesan MD - May 11, 2020 Category: Cardiology Authors: dr s venkatesan Tags: cardiology women Pregnancy and heart Uncategorized amiodarone verapamil in pregnancy avnrt avrt during pregnancy cardioversion during pregnancy dc shock during pregnancy fetal distress during dc shock peripartum cardiomyopathy vt vpd managem 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
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
Digoxin amiodarone interaction – Cardiology MCQ – Answer
New !!!
Cardiology MCQs from Cardiophile MD – Volume 3: Interactive Kindle Edition
Cardiology MCQs from Cardiophile MD – Volume 3 Paperback
When digoxin is given along with amiodarone, dose of digoxin:
Correct answer: b) Dose should be reduced by half
Important drugs which can increase the levels of digoxin are quinidine, verapamil, amiodarone and dronedarone [1]. The dose of digoxin should be halved with concomitant use of verapamil, amiodarone or dronedarone. Drugs with high levels of protein binding displace digoxin from protein binding sites and increase the effective blood levels of digoxin. Monitoring o...
Source: Cardiophile MD - May 15, 2018 Category: Cardiology Authors: Prof. Dr. Johnson Francis, MD, DM, FACC, FRCP Edin, FRCP London Tags: Cardiology MCQ DM / DNB Cardiology Entrance Source Type: blogs
For this physician, financial independence is bittersweet
I say that financial independence is bittersweet and you look at me with your jaw slack, your eyes questioning. You scan to the top of my blog, and you see the words “personal finance,” and you’re wondering if I’ve gone slightly daffy.
But then I point to my byline, personal finance with a twist, and continue on my belligerent rant. I have said before that money is a foil. A false mirage. A tangible object on which we pin our hopes and dreams. No one ever lived for money, or even died for it. We live for principles, ideals, people, objects, the unobtainable stuff that money is the first and most minor...
Source: Kevin, M.D. - Medical Weblog - May 10, 2018 Category: General Medicine Authors: < a href="https://www.kevinmd.com/blog/post-author/docg" rel="tag" > DocG, MD < /a > Tags: Finance Practice Management Source Type: blogs
Palpitations of unusual etiology
Written by Pendell Meyers, with edits by Steve SmithA male in his 60s with history of HTN and previous complaint of palpitations but with a negative holter monitor workup, presented to our ED with palpitations for the past hour, associated with lightheadedness and presyncope.He was hemodynamically stable and well appearing, but was symptomatic with palpitations and lightheadedness.Here is his 12-lead on arrival:What do you think?There is a regular, seemingly wide complex tachycardia at 224 beats per minute. The computer QRS duration is calculated at 178ms, but I believe the true QRS duration is much shorter, and in most le...
Source: Dr. Smith's ECG Blog - May 8, 2018 Category: Cardiology Authors: Pendell Source Type: blogs
Beta blocker in HOCM – Cardiology MCQ – Answer
Which of the following beta blockers is not an ideal choice in the treatment of hypertrophic obstructive cardiomyopathy?
Correct answer: d) Carvedilol
Non vasodilating betablockers are recommended for the treatment of hypertophic obstructive cardiomyopathy (Class I, Level of Evidence B, as per European Society of Cardiology Recomendations 2014). Other class I drug recommendation when beta blockers are not tolerated is verapamil. Disopyramide has a class I recommendation in combination with betablocker or verapamil.
Reference
1. Elliott PM, Anastasakis A, Borger MA, Borggrefe M, Cecchi F, Charron P, Hagege AA, Lafont A, L...
Source: Cardiophile MD - April 24, 2018 Category: Cardiology Authors: Prof. Dr. Johnson Francis, MD, DM, FACC, FRCP Edin, FRCP London Tags: Cardiology MCQ DM / DNB Cardiology Entrance Source Type: blogs
Disopyramide in HCM – Cardiology MCQ – Answer
Disopyramide is a class Ia antiarrhythmic agent which can be used in hypertrophic obstructive cardiomyopathy when beta blockers alone are ineffective. Pick out the WRONG statement regarding disopyramide in this context:
Correct answer: c) Should not be combined with verapamil
Disopyramide has a negative inotropic action and is useful in reducing left ventricular outflow tract gradients in hypertrophic obstructive cardiomyopathy and does not increase the risk of sudden cardiac death. Dose reduction is recommended when QTc exceeds 480 ms. It should be avoided in those with glaucoma and men with prostatic symptoms in view of ...
Source: Cardiophile MD - April 24, 2018 Category: Cardiology Authors: Prof. Dr. Johnson Francis, MD, DM, FACC, FRCP Edin, FRCP London Tags: Cardiology MCQ DM / DNB Cardiology Entrance Source Type: blogs
Disopyramide in HCM – Cardiology MCQ
Disopyramide is a class Ia antiarrhythmic agent which can be used in hypertrophic obstructive cardiomyopathy when beta blockers alone are ineffective. Pick out the WRONG statement regarding disopyramide in this context:
a) Regular monitoring of QTc is recommended during dose up titration
b) Has a risk of fast ventricular rate in those prone for atrial fibrillation
c) Should not be used in combination with verapamil
d) Should not be combined with other drugs which prolong the QT interval like amiodarone and sotalol
Post your answer as a comment below. Correct answer will be published on: Apr 24, 2018 @ 16:55
The post Disop...
Source: Cardiophile MD - April 22, 2018 Category: Cardiology Authors: Prof. Dr. Johnson Francis, MD, DM, FACC, FRCP Edin, FRCP London Tags: ECG / Electrophysiology ECG Library Source Type: blogs
