SSmith -DRAFT (KG- WAIT_for_STEVE) -LVOT VT-John Dunbar EKG (4-29.1-2025) - ME_to_DO

 

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MY Comment, by KEN GRAUER, MD (4/28/2025):

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Figure-1: Initial ECG in the ED.  (To improve visualization — I've digitized the original ECG using PMcardio). NOTE — I need to compared to ORIG and then Fix Figure!

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Figure-2: Repeat ECG in the ED.  (To improve visualization — I've digitized the original ECG using PMcardio). NOTE — I need to compared to ORIG and then Fix Figure!

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Figure-1: Initial ECG in the ED — obtained from a man in his 70s with 3 days of chest pain.  (To improve visualization — I've digitized the original ECG using PMcardio).

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DRAFT (as of 4/28/2025):

Had this one the other day. 60s, no medical history but didn’t go to the doctor. Had a “stressful event” 6 hrs before coming in and felt “weird”. Went to urgent care and was sent to us for his abnormal ecg.  No prior ekg except for the one done at urgent care. He mentioned he would get brief palpitations once in a while, mostly with heavy exertion, but very infrequently and none for years.  

His urgent care ekg done 20 min earlier. I assumed it was VT, namely because the urgent care EKG looks to me like possible fusion beats. Cardioversion because of hypotension didn’t work. Eventually after talking to cards we cautions gave 2.5 of metoprolol, which helped and then another 10 converted him into NSR. 

First, I would look at the heart and see whether there is a good ejection fraction or not. I would also look to see if the patient has any chronic left ventricular disease, especially ischemic, heart, disease, or any kind of cardiomyopathy. If he does, then it is standard VT, which responds to procainamide. If he is otherwise healthy, and especially if he is young, and I think about things like RVOT.

It has a morphology similar to right ventricular outflow tract VT. (RVOT).  It probably is not RVOT, but RVOT responds well to adenosine and adenosine is safe in any kind of VT, so in that case I would start with adenosine. So that probably would not work and my next step would be procainamide.  The procamio study showed it to be both more effective and safer than amiodarone for standard monomorphic VT.   Beta blockers often work, but could precipitate cardiogenic shock.  So I would only give beta blockers if there is very good LV function.

John, it is, indeed VT. But, you can tell from this EKG that electricity is not going to work. That is because it may convert, but the tachycardia will return. I know that because of that one pause where there was a sinus beat. The VT terminated for one second But then it recurred again.  This tells you that you will definitely need an antidysrhythmic. 

final dx = RVOT